Variation In Provision Of Care Research Articles

CAREGIVING NETWORKS OF DIVERSE FAMILIES: CONTEXT AND CULTURE INFLUENCES ON DEMENTIA CARE

Abstract Older adults living with dementia and their primary caregivers are embedded within larger family and formal care networks that are shaped by cultural and contextual influences. Yet information about diverse caregiving networks is sparse. This symposium focuses on the composition, structure, responsibilities, and influences of caregiving networks in supporting persons living with dementia and their primary family caregivers. Savla and colleagues identify six distinct care networks among dementia family caregivers living in economically diverse areas of rural Appalachia. Networks varied by caregivers’ emotional connectivity with family/friends, caregiver strain, role overload, loneliness, and service attitudes and utilization. Ashida and colleagues focus on changes in rural and urban dementia family caregiving networks during the COVID-19 pandemic. Network members engaging in negative social interactions increased while those engaging in uplifting interactions decreased over time, especially among urban caregivers. Bonds Johnson and colleagues examine shared decision making between African American caregivers and their relative living with dementia. Dyadic analysis revealed that while care recipients were involved in the decision-making processes, their care network’s level of the involvement varied. Angel and colleagues explore the role of caregiver characteristics, stressors, and resources for Mexican American caregivers. Depressive symptoms were significantly associated with dementia caregiver turnover, with adult children and grandchildren caregivers more likely to experience turnover than spouses. Collectively, the findings presented extend prior research on community-based dementia caregiving, broadening the focus from a single caregiver to a network of caregivers and capturing the complexities of place-based context and culture variations in care provision.

Training clinicians to become leaders of complex change: Lessons from Scotland.

Clinicians are trained to diagnose disease and recommend treatments or procedures. This is the focus of much of undergraduate training, but delivery of healthcare depends on so much more than theoretical knowledge and technical skill. It is a complex environment where professionals from different backgrounds have to work together to deliver safe pathways of care to patients who have very varied backgrounds. This can lead to inefficiency and variation in provision of care and clinical outcomes. In turn, this can negatively impact on the experience of patients and staff. Attempting to change this complex environment requires a unique set of skills. This article describes an international fellowship that creates a network of individuals skilled in quality improvement, human factors, service design and leadership.

Mixed methods evaluation of a hospital group model using an embedded research approach: study protocol

IntroductionHospital group models represent an organisational form that aims to bring together multiple provider organisations with a central headquarters and unified leadership responsible for locally managed operating units, standardised systems...

Drug allergy: diagnosis and management of drug allergy in adults, children and young people; a look at NICE guidance

When any patient uses a medicine, it has the ability to cause a noxious and unintended response known as an ‘adverse drug reaction’ (ADR). A drug allergy is defined as an ADR with specific clinical features compatible with an immunological mechanism that re-occurs on re-exposure to that offending drug. Sometimes, it can be a challenge to decide from the clinical history alone as to whether a drug reaction is allergic or not without the need for further investigations. In September 2014, the National Institute for Health and Care Excellence (NICE) published a guideline entitled ‘Drug allergy: diagnosis and management of drug allergy in adults, children and young people’.1 This was developed due to variation in provision of care for people with a suspected drug allergy and to optimise best practice advice on the diagnosis, documentation and communication of drug allergy. Our focus here will be on the recommendations for children and young people. The British Society for Allergy and Clinical Immunology (BSACI) guidelines for the management of drug allergy were published in 20082 with an update which can be found in box 1. The European Association of Allergy and Clinical Immunology (EAACI) also published an international consensus of drug allergy in February 2014.3 Both of these look at the management of drug allergy within the secondary-care and tertiary-care setting, including details on specialist investigations, in contrast to the NICE guideline, which is aimed at all health professionals who review and manage children including in primary care. Differences between these guidelines are demonstrated in table 1. View this table: Table 1 Comparison of guidelines Box 1 ### Resources

First Steps Toward Understanding the Variability in Acute Pain Service Provision and the Quality of Pain Relief in Everyday Practice Across the United Kingdom

Pain management for patients in hospital is a major problem. There is significant variation in care provision. Evidence is needed about the ways in which acute pain services are organized in order to understand whether these are linked to important differences in patient outcomes. The National Inpatient Pain Study group is a voluntary collaborative venture of inpatient pain specialists in the United Kingdom who are working toward establishing a national prospective database of service provision and activity. The objectives of this article are (1) to describe current pain service provision and activity (2) to define and monitor the quality and side effects of the primary analgesic techniques, such as central neuraxial block or systemic analgesia, and identify variations in practice. Phase 1: Surveys were conducted in two phases during 2010-2011. Information about the organization of services was collected from 121 centers via a live Website. Phase 2: The pilot clinical dataset was collected from 13 hospitals in 2011. Results indicated that staffing varied widely from one to nine nurses per hospital site. Twelve percent of hospitals did not routinely collect data. The main workload was orthopedic and general surgery based on data from 13 hospitals and 29,080 patients in 2011. Thirty-seven percent of patients reported a pain score of moderate to severe pain on the first assessment by the specialist pain team, and 21% reported severe pain. Nausea and vomiting was the most frequent adverse event reported. Sixty-nine major adverse events were logged, of which 64 documented respiratory depression (N = 29,080, 0.22%). Prospective longitudinal data has the potential to improve our understanding of variation in process and outcome measures and establish future research priorities.

Developing and comparing methods for measuring the content of care in mental health services

Measurement of what happens in mental health services is needed to describe services, identify variation in care provision and understand service outcomes. However, there is no consensus about appropriate methods or measures for content of care. Previous research has primarily used a single information source and prioritised staff over patient perspectives on content of care. This study aims to enhance understanding of how to measure content of care by developing and evaluating four instruments, each using a different measurement method. Development is described by four instruments-CaSPAR, CaRICE, CCCQ-S and CCCQ-P-which use researcher observation, staff-report and patient-report to measure the intensity and nature of care at services. Inter-rater reliability of CaRICE and CCCQ-S was investigated. Concordance between staff and patient perspectives was explored through assessing inter-rater agreement of CCCQ-S and CCCQ-P questionnaires. The convergence of data from the measures collected in an inpatient multi-site study was investigated. CaRICE demonstrated good inter-rater reliability (κ = 0.71). CCCQ-S inter-rater reliability was poor. Concordance between staff and patient reports was low: there was a trend for patients to report less care received than staff reported had been provided. Results from CaSPAR, CaRICE and CCCQ-P exhibited divergence, indicating possible differences in patient, staff and researcher perspectives. Information about content of care should be sought as close as possible to the point of delivery. There may be differing, valid perspectives about care provided by services. Further development of methods to measure content of care is required. Meanwhile, a multi-methods approach should be adopted, which allows inclusion of different perspectives (specifically including the patient's perspective) and triangulation of results from different measurement methods. CaSPAR, CaRICE and CCCQ-P can provide multi-perspective content of care measurement in inpatient services.

Key Factors for Providing Appropriate Medical Care in Secondary School Athletics: Athletic Training Services and Budget

Research suggests that appropriate medical care for interscholastic athletes is frequently lacking. However, few investigators have examined factors related to care. To examine medical care provided by interscholastic athletics programs and to identify factors associated with variations in provision of care. Cross-sectional study. Mailed and e-mailed survey. One hundred sixty-six South Carolina high schools. The 132-item Appropriate Medical Care Assessment Tool (AMCAT) was developed and pilot tested. It included 119 items assessing medical care based on the Appropriate Medical Care for Secondary School-Age Athletes (AMCSSAA) Consensus Statement and Monograph (test-retest reliability: r = 0.89). Also included were items assessing potential influences on medical care. Presence, source, and number of athletic trainers; school size; distance to nearest medical center; public or private status; sports medicine supply budget; and varsity football regional championships served as explanatory variables, whereas the school setting, region of state, and rate of free or reduced lunch qualifiers served as control variables. The Appropriate Care Index (ACI) score from the AMCAT provided a quantitative measure of medical care and served as the response variable. The ACI score was determined based on a school's response to items relating to AMCSSAA guidelines. Regression analysis revealed associations with ACI score for athletic training services and sports medicine supply budget (both P < .001) when controlling for the setting, region, and rate of free or reduced lunch qualifiers. These 2 variables accounted for 30% of the variance in ACI score (R(2) = 0.302). Post hoc analysis showed differences between ACI score based on the source of the athletic trainer and the size of the sports medicine supply budget. The AMCAT offers an evaluation of medical care provided by interscholastic athletics programs. In South Carolina schools, athletic training services and the sports medicine supply budget were associated with higher levels of medical care. These results offer guidance for improving the medical care provided for interscholastic athletes.

Medical Audit of Diabetes Mellitus in Primary Care Setting in Bosnia and Herzegovina

To assess the quality of diabetes care provided by family medicine teams in primary health centers in Bosnia and Herzegovina (BH) through a medical audit, addressing the extent to which clinical practice complied with pre-determined explicit criteria of long-term management. Retrospective analysis included randomly selected medical records of patients with type 1 or 2 diabetes mellitus treated by 18 family medicine teams at 5 locations in BH, included in the Canadian International Development Agency/World Health Organization project "Strengthening health care systems in BH with focus on primary health care/family medicine model." Audit record form contained 24 questions on sex, age, diabetes type, body mass index (BMI), hypertension, family anamnesis, annual examinations (HbA1C, BMI, lipid profile or total cholesterol, blood creatinine, neurological examination, urinalysis for albuminuria, foot care, and examination of ocular fundus), smoking habits, alcohol consumption, patient education, prescribed insulin and other drugs, and patient's health care-seeking behavior. Standardized and record forms were returned anonymously with 99.3% response rate. Records of 536 patients with diabetes were analyzed (64% women and 87% patients with diabetes mellitus type 2). Family medicine teams showed poor compliance with established criteria for diabetes control. Metabolic control (69.5%) was acceptable, but the level of monitoring complications of diabetes (foot and ocular fundus examined in 53.4% and 53% of patients, respectively) was low. There were also considerable variations in diabetes management between different centers as well as between the teams in the same center. The audit revealed deficiencies in the quality of diabetes care and variations in care provision between primary care teams. Clinical guidelines and continuing education about acceptable diabetes care should be developed and implemented in BH.

Variability in the organisation and management of hospital care for COPD exacerbations in the UK

Previous smaller UK audits have demonstrated wide variation in organisation, resources, and process of care for acute chronic obstructive pulmonary disease (COPD) admissions. Smallest units appeared to do less well. UK acute hospitals supplied information on (1) resources and organisation of care, (2) clinical data on process of care and outcomes for up to 40 consecutive COPD admissions. Comparisons were made against national recommendations. Eight thousand and thirteen admissions involved 7529 patients from 233 units (93% of UK acute Trusts). Twenty-six percent of units had at most one whole-time equivalent respiratory consultant while 12% had at least four. Thirty percent patients were admitted under a respiratory specialist and 48% discharged under their care whilst 28% had no specialist input at all. Variation in care provision was wide across all hospitals but patients in smaller hospitals had less access to specialist respiratory or admission wards, pulmonary rehabilitation programs, specialty triage or an early discharge scheme. Six percent of units did not have access to NIV and 18% to invasive ventilatory support. There remains wide variation in all aspects of acute hospital COPD care in the UK, with smaller hospitals offering fewest services. Those receiving specialist input are more likely to be offered interventions of proven effect. Management guidelines alone are insufficient to address inequalities of care and a clear statement of minimum national standards for resource provision and organisation of COPD care are required. This study provides a unique insight into the current state of care for patients admitted with COPD exacerbations in the UK.

The ambiguous relationship between practice variation and appropriateness of care: an agenda for further research

The analysis of variation in the use of health care services, and particularly of practice variation, has been the subject of renewed interest because of the view that the inappropriate use of procedures could be a major cause of these differences. In this article, recent literature is reviewed and the results of personal research are described on both the variation in care provision and on appropriateness assessment. In the few studies which have focussed on both subjects no evidence has yet been found to suggest that practice variation is to be explained by differences in appropriateness rates. However, there are still many methodological pitfalls in both variation analyses (statistical problems) and appropriateness assessment (reliability of the judgement), implying that this conclusion is far from definitive. More research should therefore be conducted on methodological questions of variation analysis and appropriateness assessment. Furthermore in variation analysis the relative contribution of all potential determinants has to be studied on the various levels of care provision. Finally, to study the relationship between practice variation and appropriateness of care, the clinical problem and not the procedure should be the starting point.