Variation In Quality Of Care Research Articles

Decomposition of the wealth gradient in maternal healthcare quality in low- and middle-income countries

Although access to health services by poor populations has improved in most low- and middle-income countries, wealth remains associated with better quality of care that in turn leads to better health outcomes. Understanding the patterns of such inequities can inform the design of policies to improve services received by poor populations. We employ regression and inequality decomposition analyses using household survey data from 58 low- and middle-income countries between 2010 and 2021 to characterize inequity in quality of antenatal care, to test at which levels inequity exists, and to assess at which levels inequities are most pronounced. We find that in most countries and in both rural and urban areas, wealthier women are more likely to receive high-quality antenatal care than their poorer peers who reside in the same locality (village or neighborhood), even when attending similar types of health facilities (public vs. private, and primary care facilities vs. hospitals). However, although inequity exists at such a local level, most of the wealth gradient in quality of antenatal care is explained by variation in quality of care between wealthier and poorer localities.

Comparing methods for assessing the reliability of health care quality measures.

Quality measurement plays an increasing role in U.S. health care. Measures inform quality improvement efforts, public reporting of variations in quality of care across providers and hospitals, and high-stakes financial decisions. To be meaningful in these contexts, measures should be reliable and not heavily impacted by chance variations in sampling or measurement. Several different methods are used in practice by measure developers and endorsers to evaluate reliability; however, there is uncertainty and debate over differences between these methods and their interpretations. We review methods currently used in practice, pointing out differences that can lead to disparate reliability estimates. We compare estimates from 14 different methods in the case of two sets of mental health quality measures within a large health system. We find that estimates can differ substantially and that these discrepancies widen when sample size is reduced.

GPs' perspectives on diagnostic tests for children: a qualitative interview study.

Most healthcare contacts for children in the UK occur in general practice. Diagnostic tests can be beneficial in narrowing differential diagnoses; however, there is substantial variation in the use of tests for children in general practice. Unwarranted variation in testing can lead to variation in quality of care and may exacerbate health inequities. To our knowledge, no previous study has tried to understand why variation in testing exists for children in general practice. To explore GPs' perspectives on using diagnostic tests for children in primary care and the underlying drivers of variation. Qualitative study in which semi-structured interviews were conducted with GPs and trainee GPs in England. Interviews were conducted with 18 GPs and two trainee GPs between April and June 2023. The interviews were transcribed and analysed using reflexive thematic analysis. GPs reflected that their approach to testing in children differed from their approach to testing in adults: their threshold to test was higher, and their threshold to refer to specialists was lower. GPs' perceptions of test utility varied, including objective testing for asthma. Perceived drivers of variation in testing were intrinsic (clinician-specific) factors relating to their risk tolerance and experience; and extrinsic factors, including disease prevalence, parental concern and expectations of health care, workforce changes leading to fragmentation in care, time constraints, and differences in guidelines. The findings of this study identify actionable issues for clinicians, researchers, and policymakers to address gaps in education, evidence, and guidance, reduce unwarranted differences in test use, and improve the quality of health care delivered to children in general practice.

Measuring Quality Care for Adult ADHD Patients: How Much Does Gender and Gender Identity Matter?

Objective: Studies show adult ADHD presents differently in men and women, however few studies contrast ADHD in cisgender and gender diverse adults. We assessed care differences between these groups using previously identified quality measures (QMs). Methods: Using EHR data, we matched a group of male ADHD patients to a female group. We followed the same procedure with a cisgender group and one identified as gender diverse through a gender dysphoria diagnosis. QM achievement was measured using logistic regression models. Results: Most QMs exhibited increasing achievement over time for all groups. Variations in care quality between males and females persisted, with female patients achieving QMs more often. There were no appreciable differences between the cisgender and gender diverse groups. Conclusion: Though quality care for adult ADHD improved from 2010 to 2020, differences between male and female patients lingered. This effect was not observed in cisgender and gender diverse patients.

Development of a Multi-site Curriculum for Inequities in Newborn Care (CINC) Informed by Pediatric Resident and Community Engagement.

Inequities in health care are a well-identified contributor to adverse outcomes in neonates of vulnerable populations. 1 2022 March of Dimes Report Card. Accessed March 8, 2023. 〈https://www.marchofdimes.org/report-card〉 Google Scholar , 2 Warren M.D. Hirai A.H. Lee V. Accelerating Upstream Together: Achieving Infant Health Equity in the United States by 2030. Pediatrics. Published online January. 2022; 3e2021052800https://doi.org/10.1542/peds.2021-052800 Crossref Scopus (2) Google Scholar , 3 Sigurdson K. Morton C. Mitchell B. Profit J. Disparities in NICU quality of care: a qualitative study of family and clinician accounts. Journal of Perinatology. 2018; 38: 600-607https://doi.org/10.1038/s41372-018-0057-3 Crossref PubMed Scopus (61) Google Scholar Societal and institutional inequities rooted within implicit biases and racism result in variable quality of care in the nursery, such as differences in time spent skin-to-skin with infants, clinical resource allocation based on racial background, and a lack of motivation to establish a therapeutic alliance with families who have differing social and cultural needs. 3 Sigurdson K. Morton C. Mitchell B. Profit J. Disparities in NICU quality of care: a qualitative study of family and clinician accounts. Journal of Perinatology. 2018; 38: 600-607https://doi.org/10.1038/s41372-018-0057-3 Crossref PubMed Scopus (61) Google Scholar Most significantly, this inequitable care results in the increased mortality of non-Hispanic black and Hispanic infants as compared to infants of non-Hispanic white backgrounds. 4 National Vital Statistics Reports Volume 69, Number 7 July 16, 2020, Infant Mortality in the United States, 2018 : Data From the Period Linked Birth/Infant Death File. Google Scholar In light of these inequities, the Academic Pediatrics Association (APA) implemented initiatives rooted in active anti-racism to dismantle oppressive power structures across pediatric organizations. 5 Cohen A. et al. Changing Who Has a Seat and Voice at the Table: How the Academic Pediatric Association is Responding to Systemic Racism. Academic Pediatrics. 2022; 22: 352-355https://doi.org/10.1016/j.acap.2022.01.002 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar This urgent commitment to action is further supported by the Association of Pediatric Program Directors (APPD) which maintains that anti-racism involves actively dismantling racism in all that we do. 6 Blankenburg B. et al. Dismantling Racism: Association of Pediatric Program Directors’ Commitment to Action. Academic Pediatrics. 2020; 20: 1051-1053https://doi.org/10.1016/j.acap.2020.08.017 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Focus groups of trainees at 4 Bay Area academic medical centers explored gaps in education on newborn health inequities to best understand how to support providers in actively practicing anti-racism in clinical care. Trainees spotlight inequities in their rotations, but feel helpless to address them given a lack of action-based tools, education on inequities, protected time for reflection, and faculty role-modeling. 7 Hume P. , Bowers K. , Robertson L. , et al. Residents’ Perspectives on Neonatal Health Inequities to Guide an Innovative Curriculum. Poster Presentation presented at: APPD; March 2023; Atlanta, Georgia. Google Scholar Given these highlighted gaps, we sought to provide our pediatrics faculty and trainees with action-oriented education to address inequities.

Civil commitment perspectives and experiences among friends and family of people who use illicit opioids in Massachusetts, USA.

Civil commitment statutes allow qualified individuals to petition for court-mandated commitment for someone with a substance use disorder (SUD). Despite a lack of empirical evidence showing efficacy of involuntary commitment, these statutes are prevalent worldwide. We examined perspectives on civil commitment among family members and close friends of people who use illicit opioids in Massachusetts, U.S.A. Eligible individuals were Massachusetts residents, ≥18 years of age, did not use illicit opioids but had a close relationship with someone who did. We used a sequential mixed methods approach in which semi-structured interviews (N=22) were followed by a quantitative survey (N=260). Thematic analysis was used to analyze qualitative data and survey data were analyzed using descriptive statistics. While some family members were influenced by SUD professionals to petition for civil commitment, influence from social networks based on personal experience was more common. Motivations for civil commitment included initiating recovery and believing that commitment would reduce overdose risk. Some reported that it afforded them respite from caring for, and worrying about, their loved one. A minority discussed increases in overdose risk following a period of forced abstinence. Participants expressed concerns about the variable quality of care during commitment, largely based on the use of corrections facilities for civil commitment in Massachusetts. A minority endorsed the use of these facilities for civil commitment. Despite participants' uncertainty and the harms stemming from civil commitment, including increased risk of overdose after forced abstinence and the use of corrections facilities, family members resorted to this mechanism to reduce immediate overdose risk. Our findings indicate that peer support groups are an appropriate forum to disseminate information about evidenced-based treatment and that family members and others close to those with SUD often lack adequate support for, and respite from, the stress of caring for them.

Measuring variation in the quality of systemic anti-cancer therapy delivery across hospitals: A national population-based evaluation.

6593 Background: To date, there has been little systematic assessment of the quality of care associated with systemic anti-cancer therapy (SACT) delivery across national healthcare systems. We evaluated hospital-level toxicity rates during SACT treatment as a means of identifying variation in care quality. Methods: All colorectal cancer patients receiving SACT within 106 English National Health Service hospitals between 2016 and 2019 were included. Severe acute toxicity rates were derived from hospital administrative data using a validated coding framework. Variation in hospital-level toxicity rates was assessed separately in the adjuvant and metastatic settings. Toxicity rates were adjusted for age, sex, comorbidity, performance status, tumour site, and TNM staging. Results: Of the 8,173 patients receiving SACT in the adjuvant setting, 2,074 (25%) had a toxicity with adjusted hospital-level rates varying from 11% to 49%. Of the 7,683 patients receiving SACT in the metastatic setting, 3,625 (47%) had a toxicity with adjusted hospital-level rates varying from 25% to 67%. Compared to the national mean toxicity rate in the adjuvant cohort, six hospitals were more than 2 standard deviations (2SD) above, and four hospitals were more than 2SD below. Similarly, in the metastatic cohort, six hospitals were more than 2SD above, and seven hospitals were more than 2SD below the national mean toxicity rate. Conclusions: There is substantial variation in hospital-level severe acute toxicity rates in both the adjuvant and metastatic settings, despite comprehensive risk-adjustment. Ongoing reporting of this performance indicator can be used to focus further investigation of toxicity rates and stimulate quality improvement initiatives to enhance care.

Applying Quality Indicators to Examine Quality of Care During Active Surveillance in Low-Risk Prostate Cancer: A Population-Based Study.

Although a few studies have reported wide variations in quality of care in active surveillance (AS), there is a lack of research using validated quality indicators (QIs). The aim of this study was to apply evidence-based QIs to examine the quality of AS care at the population level. QIs were measured using a population-based retrospective cohort of patients with low-risk prostate cancer diagnosed between 2002 and 2014. We developed 20 QIs through a modified Delphi approach with clinicians targeting the quality of AS care at the population level. QIs included structure (n=1), process of care (n=13), and outcome indicators (n=6). Abstracted pathology data were linked to cancer registry and administrative databases in Ontario, Canada. A total of 17 of 20 QIs could be applied based on available information in administrative databases. Variations in QI performance were explored according to patient age, year of diagnosis, and physician volume. The cohort included 33,454 men with low-risk prostate cancer, with a median age of 65 years (IQR, 59-71 years) and a median prostate-specific antigen level of 6.2 ng/mL. Compliance varied widely for 10 process QIs (range, 36.6%-100.0%, with 6 [60%] QIs >80%). Initial AS uptake was 36.6% and increased over time. Among outcome indicators, significant variations were observed by patient age group (10-year metastasis-free survival was 95.0% for age 65-74 years and 97.5% in age <55 years) and physician average annual AS volume (10-year metastasis-free survival was 94.5% for physicians with 1-2 patients with AS and 95.8% for those with ≥6 patients with AS annually). This study establishes a foundation for quality-of-care assessments and monitoring during AS implementation at a population level. Considerable variations appeared with QIs related to process of care by physician volume and Qis related to outcome by patient age group. These findings may represent areas for targeted quality improvement initiatives.

Informatics approaches to improve the quality of dental care.

Despite technological advances, challenges exist in US dental care, including variations in quality of care, access and untreated dental needs. The implementation of learning health systems (LHSs) in dentistry can help to address these challenges. LHSs use robust informatics infrastructure including data and technology to continuously measure and improve the quality and safety of care and can help to reduce costs and improve patient outcomes. The use of EHRs and standardized diagnostic terminologies are highlighted, as they allow for the storage and sharing of patient data, providing a comprehensive view of a patient's medical and dental history, and can be used to identify patterns and trends to improve the delivery of care. The BigMouth Dental Data Repository is an example of an informatic platform that aggregates patient data from multiple institutions and is being used to for scientific inquiry to improve oral health.

A183 VARIATION IN HEALTH SERVICES UTILIZATION AND RISK OF SURGERY ACROSS CHILDREN WITH INFLAMMATORY BOWEL DISEASE: A MULTIPROVINCE COHORT STUDY

Abstract Background Marked variation in access to care and health services utilization is a marker of variation in quality of care. With the rising incidence of pediatric inflammatory bowel disease (IBD), we must understand variation in access to and outcomes of care to improve quality. Purpose Describe variation in care for pediatric IBD treated in 4 Canadian provinces. Method Incident cases of IBD diagnosed in children &amp;lt;16y were identified from health administrative data in Alberta (AB), Manitoba, Nova Scotia, and Ontario (ON) using validated algorithms. Children were assigned to one of 8 centres of care using a hierarchical assessment of health services use within 6 months of diagnosis. Children treated by adult gastroenterologists or community-based pediatric gastroenterologists were excluded due to small sample size. Outcomes included IBD-related hospitalizations, emergency department (ED) visits (AB/ON only), and IBD-related abdominal surgery. Hospitalizations and ED visits were counted cumulatively from 6-60 months after diagnosis. The risk of first surgery was defined during the same 6-60 month period. Mixed-effects meta-analysis was used to pool results across centres. Heterogeneity among centres was quantified using I2 (variation in pooled event rates between centres) and τ (standard deviation of the true event rates). R2 quantified the residual heterogeneity in outcomes not attributable to among-province variation. Result(s) We identified 3777 incident cases of pediatric IBD, 2936 (78%) of which were treated at 8 pediatric centres. The number of hospitalizations was 0.67 (95% CI 0.56-0.79) per person with high between-centre heterogeneity (I2 84%, τ 0.1556). Provincial differences accounted for 93% of heterogeneity across centres (residual heterogeneity: I2 29%, τ 0.0412). Hospitalizations were less frequent in AB than other provinces (0.43 vs. 0.72-0.78). Children averaged 1.94 IBD-related ED visits, with significant heterogeneity (I2 99%, τ 1.33) with 99.7% of heterogeneity attributable to among-province differences (residual heterogeneity: I2 32%; τ 0.074). Mean ED visits were 1.1 visits in ON (I2 39%) and 3.7 in AB (I2 0%). Intestinal resection was required by 12% (95% CI 0.08-0.15) of Crohn’s patients with high among-centre heterogeneity (I2 81%, τ 0.042), and low (19%) heterogeneity due to provincial differences (residual heterogeneity: I2 76%; τ 0.039). Colectomy was required by 12% (95% CI 10-14) of children with ulcerative colitis (UC) with no between-centre heterogeneity (I2 0%, τ 0). Conclusion(s) There is a high degree of between-province (but not between-centre, within province) variability in health services utilization among children with IBD. There was significant between-centre variability in surgery rates for Crohn’s, but not colectomy for UC. Differences in patient characteristics or provincial health systems may be more important predictors of variation in care. Surgery for Crohn’s disease may be a target for inter-centre quality improvement efforts. Please acknowledge all funding agencies by checking the applicable boxes below CCC Disclosure of Interest None Declared

Are we delivering high-quality medical oncology care? A national comparison of severe acute toxicity from systemic anti-cancer therapy

BackgroundIn the precision medicine era the complexity of systemic anti-cancer therapy (SACT) delivery and their associated toxicities have also increased. However, there has been little systematic assessment of the quality of care associated with systemic anti-cancer therapy delivery across national healthcare systems. We evaluated hospital-level severe acute toxicity rates during SACT treatment as a means of identifying variation in care quality. MethodsAll colorectal cancer (CRC) patients receiving SACT within 106 English National Health Service (NHS) hospitals between 2016 and 2019 were included.Severe acute toxicity rates were derived from hospital administrative data using a validated coding framework. Toxicity rates were adjusted for age, sex, comorbidity, performance status, tumour site, and TNM staging. Variation in hospital-level toxicity rates was assessed separately in the adjuvant and first-line metastatic settings. Results8,173 patients received SACT in the adjuvant setting, and 7,683 patients in the first-line metastatic setting. Adjusted severe acute toxicity rates varied between hospitals from 11% to 49% for the adjuvant cohort, and from 25% to 67% for the metastatic cohort.Compared to the national mean toxicity rate in the adjuvant cohort, six hospitals were more than 2 standard deviations (2SD) above, and four hospitals were more than 2SD below. In the metastatic cohort, six hospitals were more than 2SD above, and seven hospitals were more than 2SD below the national mean toxicity rate.Overall, 12 hospitals (12%) had toxicity rates more than 2SD above the national mean, and 11 (10%) had rates more than 2SD below. ConclusionThere is substantial variation in hospital-level severe acute toxicity rates in both the adjuvant and metastatic settings, despite risk-adjustment. Ongoing national public reporting of this performance indicator can be used investigate reasons for variation in toxicity rates and stimulate quality improvement initiatives to improve care. This may include increasing centralisation of SACT care delivery to minimise variation. This approach can be applied across different cancer types and in many different countries where similar regional or national clinical and administrative hospital datasets are available.

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Variation in quality of care by medical institute level in China: a systematic review protocol

IntroductionQuality variation has been widely witnessed and discussed in China. However, limited evidence reveals quality gaps by the medical institute level, especially between hospitals and primary care institutes. This systematic...

Measuring variation in the quality of systemic anti-cancer therapy delivery across hospitals: A national population-based evaluation

AimTo date, there has been little systematic assessment of the quality of care associated with systemic anti-cancer therapy (SACT) delivery across national healthcare systems. We evaluated hospital-level toxicity rates during SACT treatment as a means of identifying variation in care quality. MethodsAll colorectal cancer (CRC) patients receiving SACT within 106 English National Health Service (NHS) hospitals between 2016 and 2019 were included.Severe acute toxicity rates were derived from hospital administrative data using a validated coding framework. Variation in hospital-level toxicity rates was assessed separately in the adjuvant and metastatic settings. Toxicity rates were adjusted for age, sex, comorbidity, performance status, tumour site, and TNM staging. ResultsEight thousand one hundred and seventy three patients received SACT in the adjuvant setting, and 7,683 patients in the metastatic setting. Adjusted severe acute toxicity rates varied between hospitals from 11% to 49% for the adjuvant cohort, and from 25% to 67% for the metastatic cohort.Compared to the national mean toxicity rate in the adjuvant cohort, six hospitals were more than two standard deviations (2SD) above, and four hospitals were more than 2SD below. In the metastatic cohort, six hospitals were more than 2SD above, and seven hospitals were more than 2SD below the national mean toxicity rate.Overall, 12 hospitals (12%) had toxicity rates more than 2SD above the national mean, and 11 (10%) had rates more than 2SD below. ConclusionThere is substantial variation in hospital-level severe acute toxicity rates in both the adjuvant and metastatic settings, despite risk-adjustment. Ongoing reporting of this performance indicator can be used to focus further investigation of toxicity rates and stimulate quality improvement initiatives to improve care.

A novel approach to attribute responsible physicians using inpatient claims.

More robust attribution methods are necessary to understand physician-level variation in quality of care across risk-adjusted inpatient measures. We address a gap in the literature involving attribution of physicians to inpatient stays using administrative claims data, in which rule-based methods often inadequately attribute physicians. Methodology comparison study using a cross-section of inpatient stays. A novel approach is proposed in which physicians' relative degrees of responsibility for inpatient stays are expressed through physician-specific attribution ratios informed by existing patient characteristics and comorbidities. Attribution results are compared with the rule-based benchmark method for 7 CMS-defined clinical cohorts, including a COVID-19 cohort. Using 6,835,460 unique patient encounters during 2020 (n = 136,339 in out-of-sample cohort), the proposed approach favored specialists generally considered responsible for primary clinical conditions when compared with the benchmark. The most salient shift within the acute myocardial infarction (+17.0%), heart failure (+20.2%), and coronary artery bypass graft (+4.0%) cohorts was toward the cardiovascular diseases specialty, and the chronic obstructive pulmonary disease (+24.0%) and pneumonia (+16.2%) cohorts resulted in a shift toward the pulmonary diseases specialty. The COVID-19 cohort resulted in considerable shifts toward infectious diseases and pulmonary diseases specialties (+17.4% and +14.1%, respectively). The stroke cohort experienced a considerable shift toward the neurology specialty (+42.2%). We provide a robust method to attribute physicians to patients, which is a necessary tool to understand physician-level variation in quality of care within the inpatient acute care setting. The proposed method provides consistency across facilities and eliminates unattributed patients resulting from unsatisfied business rules.

Racial and ethnic disparities in oral healthcare quality among children enrolled in Medicaid and CHIP.

ObjectivesAddressing inequities in oral health care requires identification of which populations are experiencing performance gaps and the extent of those gaps. This study used Dental Quality Alliance (DQA) measures to examine variations in quality by race and ethnicity.MethodsWe used eligibility and claims data for 2018 for children aged <21 years for state Medicaid/CHIP programs available through the Transformed Medicaid Statistical Information System. For a subset of states with sufficient data quality, we calculated DQA measures of utilization of services, oral evaluation, and topical fluoride. The measures were stratified by race and ethnicity, age, sex, geographic location, and language. We used bivariate logistic regression to analyze relative disparities.ResultsVariations in measure scores were noted between racial and ethnic groups. Measure scores were typically lower for non‐Hispanic black and American Indian/Alaskan Native children and higher for non‐Hispanic Asian and Hispanic children compared with non‐Hispanic white children. There also was variation in the patterns of disparities between states. More than two‐thirds of states had insufficient race and ethnicity data (>10% missing) to reliably report stratified measure scores.ConclusionsBecause disparities vary by state, each Medicaid/CHIP program should evaluate variations in care quality in the context of the population it serves. A critical first step is to improve collection of race and ethnicity. These measurements can be used to set improvement goals that not only raise quality of care for the population overall but also close gaps in performance between racial and ethnic groups.

Physician Practice Pattern Variations in Common Clinical Scenarios Within 5 US Metropolitan Areas

While variations in quality of care have been described between US regions, physician-level practice pattern variations within regions remain poorly understood, notably among specialists. To examine within-area physician-level variations in decision-making in common clinical scenarios where guidelines specifying appropriateness or quality of care exist. This cross-sectional study used 2016 through 2019 data from a large nationwide network of commercial insurers, provided by Health Intelligence Company, LLC, within 5 metropolitan statistical areas (MSAs). Physician-level variations in appropriateness and quality of care were measured using 14 common clinical scenarios involving 7 specialties. The measures were constructed using public quality measure definitions, clinical guidelines, and appropriateness criteria from the clinical literature. Physician performance was calculated using a multilevel model adjusted for patient age, sex, risk score, and socioeconomic status with physician random effects. Measure reliability for each physician was calculated using the signal-to-noise approach. Within-MSA variation was calculated between physician quintiles adjusted for patient attributes, with the first quintile denoting highest quality or appropriateness and the fifth quintile reflecting the opposite. Data were analyzed March through October 2021. Fourteen measures of quality or appropriateness of care, with 2 measures each in the domains of cardiology, endocrinology, gastroenterology, pulmonology, obstetrics, orthopedics, and neurosurgery. A total of 8788 physicians were included across the 5 MSAs, and about 2.5 million unique patient-physician pairs were included in the measures. Within the 5 MSAs, on average, patients in the measures were 34.7 to 40.7 years old, 49.1% to 52.3% female, had a mean risk score of 0.8 to 1.0, and more likely to have an employer-sponsored insurance plan that was either self-insured or fully insured (59.8% to 97.6%). Within MSAs, physician-level variations were qualitatively similar across measures. For example, statin therapy in patients with coronary artery disease ranged from 54.3% to 70.9% in the first quintile of cardiologists to 30.5% to 42.6% in the fifth quintile. Upper endoscopy in patients with gastroesophageal reflux disease without alarm symptoms spanned 14.6% to 16.9% in the first quintile of gastroenterologists to 28.2% to 33.8% in the fifth quintile. Among patients with new knee or hip osteoarthritis, 2.1% to 3.4% received arthroscopy in the first quintile of orthopedic surgeons, whereas 25.5% to 30.7% did in the fifth quintile. Appropriate prenatal screening among pregnant patients ranged from 82.6% to 93.6% in the first quintile of obstetricians to 30.9% to 65.7% in the fifth quintile. Within MSAs, adjusted differences between quintiles approximated unadjusted differences. Measure reliability, which can reflect consistency and reproducibility, exceeded 70.0% across nearly all measures in all MSAs. In this cross-sectional study of 5 US metropolitan areas, sizeable physician-level practice variations were found across common clinical scenarios and specialties. Understanding the sources of these variations may inform efforts to improve the value of care.

Variations in Quality of Care by Sex and Social Determinants of Health Among Younger Adults With Acute Myocardial Infarction in the US and Canada

Quality of care of young adults with acute myocardial infarction (AMI) may depend on health care systems in addition to individual-level factors such as biological sex and social determinants of health (SDOH). To examine whether the quality of in-hospital and postacute care among young adults with AMI differs between the US and Canada and whether female sex and adverse SDOH are associated with a low quality of care. This retrospective cohort analysis used data from 2 large cohorts of young adults (aged ≤55 years) receiving in-hospital and outpatient care for AMI at 127 centers in the US and Canada. Data were collected from August 21, 2008, to April 30, 2013, and analyzed from July 12, 2019, to March 10, 2021. Sex, SDOH, and health care system. Opportunity-based quality-of-care score (QCS), determined by dividing the total number of quality indicators of care received by the total number for which the patient was eligible, with low quality of care defined as the lowest tertile of the QCS. A total of 4048 adults with AMI (2345 women [57.9%]; median age, 49 [interquartile range, 44-52] years; 3004 [74.2%] in the US) were included in the analysis. Of 3416 patients with in-hospital QCS available, 1061 (31.1%) received a low QCS, including more women compared with men (725 of 2007 [36.1%] vs 336 of 1409 [23.8%]; P < .001) and more patients treated in the US vs Canada (962 of 2646 [36.4%] vs 99 of 770 [12.9%]; P < .001). Conversely, low quality of post-AMI care (748 of 2938 [25.5%]) was similarly observed for both sexes, with a higher prevalence in the US (678 of 2346 [28.9%] vs 70 of 592 [11.8%]). In adjusted analyses, female sex was not associated with low QCS for in-hospital (odds ratio [OR], 1.05; 95% CI, 0.87-1.28) and post-AMI (OR, 1.07; 95% CI, 0.88-1.30) care. Conversely, being treated in the US was associated with low in-hospital (OR, 2.93; 95% CI, 2.16-3.99) and post-AMI (OR, 2.67; 95% CI, 1.97-3.63) QCS, regardless of sex. Of all SDOH, only employment was associated with higher quality of in-hospital care (OR, 0.72; 95% CI, 0.59-0.88). Finally, only in the US, low quality of in-hospital care was associated with a higher 1-year cardiac readmissions rate (234 of 962 [24.3%]). These findings suggest that beyond sex, health care systems and SDOH that depict social vulnerability are associated with quality of AMI care. Taking into account SDOH among young adults with AMI may improve quality of care and reduce readmissions, especially in the US.

Disparate healthcare experiences of people living with overweight or obesity in England.

BackgroundEnsuring that patients have high quality, equitable experiences in healthcare is a high priority in the UK. As such, identifying and addressing areas where patient experiences are unsatisfactory and inequitable is of high priority, and has been included as part of the National Health Service (NHS) England equity objectives.MethodsThe healthcare experiences of people who identified as living with overweight or obesity were gathered from freely available websites using the Patient Experience Platform (PEP). PEP was used to gather and analyse all comments from NHS UK, Google, Facebook and Twitter that related to care experiences of people who identified as living with overweight or obesity across all NHS Acute and Specialist Trusts and all general practitioners (GPs) in England from 01/01/2018 to 31/12/2020. These healthcare experiences were analysed to provide care quality metrics, a comparison of care across regions of England, and to explore associations between behavioural clusters of personality attributes, values and sentiment with care quality metrics.FindingsPerceptions of the quality of care were significantly lower for people who identified as living with overweight or obesity compared to people who didn't identify as living with overweight or obesity across all regions for ‘Effective Treatment’ and ‘Emotional Support’. The perceived quality of care metrics can be predicted by the behavioral clusters, where for instance, the experiences of people who identified as living with overweight or obesity in the negative behavioral cluster have a lower overall perceived quality of care score. Themes arising from the data also highlighted that barriers quality care experienced by people who identified as living with obesity include the speed of access, effective treatment, and emotional support, with stigmatising healthcare experiences are reported.InterpretationThe findings of this study provide insights into the experiences reported via freely available websites, of people who self-identified as living with overweight or obesity in healthcare in England. These insights demonstrate that the perceived quality of care was lower for people who identified as living with overweight or obesity compared to the general population, and that there is regional variation in care quality. The study has also shown that patient experiences differ based on personality attributes, values and sentiment, highlighting the need for patient-centred care and personalised approaches. These findings hold important considerations for healthcare and policy makers aiming to address healthcare inequity.

Urban–Rural Variations in Quality of Care Among Patients With Cancer in California

Previous research suggests cancer patients living in rural areas have lower quality of care, but population-based studies have yielded inconsistent results. This study examines the impact of rurality on care quality for 7 cancer types in California. Breast, ovarian, endometrial, cervix, colon, lung, and gastric cancer patients diagnosed from 2004 to 2017 were identified in the California Cancer Registry. Multivariable logistic regression and proportional hazards models were used to assess effects of residential location on quality of care and survival. Stratified models examined the impact of treatment at National Cancer Institute designated cancer centers (NCICCs). Quality of care was evaluated using Commission on Cancer measures. Medical Service Study Areas were used to assess urban/rural status. Data were collected in 2004-2019 and analyzed in 2020. 989,747 cancer patients were evaluated, with 14% living in rural areas. Rural patients had lower odds of receiving radiation after breast conserving surgery compared to urban residents. Colon and gastric cancer patients had 20% and 16% lower odds, respectively, of having optimal surgery. Rural patients treated at NCICCs had greater odds of recommended surgery for most cancer types. Survival was similar among urban and rural subgroups. Rural residence was inversely associated with receipt of recommended surgery for gastric and colon cancer patients not treated at NCICCs, and for receiving recommended radiotherapy after breast conserving surgery regardless of treatment location. Further studies investigating the impact of care location and availability of supportive services on urban-rural differences in quality of care are warranted.