Variation In Quality Of Care Research Articles

Measuring hospital-specific disparities by dual eligibility and race to reduce health inequities.

ObjectiveTo propose and evaluate a metric for quantifying hospital‐specific disparities in health outcomes that can be used by patients and hospitals.Data Sources/Study SettingInpatient admissions for Medicare patients with acute myocardial infarction, heart failure, or pneumonia to all non‐federal, short‐term, acute care hospitals during 2012‐2015.Study DesignBuilding on the current Centers for Medicare and Medicaid Services methodology for calculating risk‐standardized readmission rates, we developed models that include a hospital‐specific random coefficient for either patient dual eligibility status or African American race. These coefficients quantify the difference in risk‐standardized outcomes by dual eligibility and race at a given hospital after accounting for the hospital's patient case mix and proportion of dual eligible or African American patients. We demonstrate this approach and report variation and performance in hospital‐specific disparities.Principal FindingsDual eligibility and African American race were associated with higher readmission rates within hospitals for all three conditions. However, this disparity effect varied substantially across hospitals.ConclusionOur models isolate a hospital‐specific disparity effect and demonstrate variation in quality of care for different groups of patients across conditions and hospitals. Illuminating within‐hospital disparities can incentivize hospitals to reduce inequities in health care quality.

Using a mentorship model to localise the Practical Approach to Care Kit (PACK): from South Africa to Brazil

Brazil’s Sistema Único de Saúde, or Unified Health System policy, has delivered major improvements in health coverage and outcomes, but challenges remain, including the rise of non-communicable diseases (NCDs) and...

Should interventions to reduce variation in care quality target doctors or hospitals?

Interventions to reduce variation in care quality are increasingly targeted at both individual doctors and the organisations in which they work. Concerns remain about the scope and consequences for such performance management, the relative contribution of individuals and organisations to observed variation, and whether performance can be measured reliably.This study explores these issues in the context of the English National Health Service by analysing comprehensive administrative data for all patients treated for four clinical conditions (acute myocardial infarction, hip fracture, pneumonia, ischemic stroke) and two surgical procedures (coronary artery bypass, hip replacement) during April 2010–February 2013. Performance indicators are defined as 30-day mortality, 28-day emergency readmission and inpatient length of stay. Three-level hierarchical generalised linear mixed models are estimated to attribute variation in case-mix adjusted indicators to individual doctors and hospital organisations.Except for length of stay after hip replacement, no more than 11% of variation in case-mix adjusted performance indicators can be attributed to doctors and organisations with the rest reflecting random chance and unobserved patient factors. Doctor variation exceeds hospital variation by a factor of 1.2 or more. However, identifying poor performance amongst doctors is hampered by insufficient numbers of cases per doctor to reliably estimate their individual performances. Policy makers and regulators should therefore be cautious when targeting individual doctors in performance improvement initiatives.

Veterans’ Care: The Author Replies

Letters Health AffairsVol. 37, No. 4: Culture Of Health, The ACA & More Veterans’ Care: The Author RepliesRisha Gidwani-Marszowski AffiliationsVA Health Economics Resource Center Menlo Park, CaliforniaPUBLISHED:April 2018Free Accesshttps://doi.org/10.1377/hlthaff.2018.0106AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSVeterans healthQuality of careMarketsMedicareGovernment programs and policiesClinical practiceHospital carePublic healthOrganization of careMy colleagues and I agree with William Weeks that markets matter and there is often variation in quality of care across locations. We controlled for this variation in our study (Jan 2018) using a fixed effect for geographic region (see the article’s online appendix for further explanation of the use and interpretation of this effect).1 Thus, our work identifies the highest-performing system within a particular market. On average, across the country, the Department of Veterans Affairs (VA) provides higher-quality care than Medicare.Weeks suggests the VA should design programs encouraging veterans to use the highest-quality health care within a region. We support the development of such programs.On a broader note, Weeks states that outcomes for veterans would be better if they used high-quality community care, citing his own study in support. However, our work as well as systematic literature reviews provide evidence to the contrary: The VA provides similar- or higher-quality care than the private sector.2 Furthermore, Weeks’s paper notes that due to a lack of risk adjustment, “no conclusions should be drawn regarding the relative performance of VHA and the private sector from this analysis.”3VA-to-Medicare comparisons provide important information about how health care system organization and financing affect quality of care. In the case of end-of-life cancer care, after adjusting for market characteristics, the VA outperforms Medicare.NOTES1 To access the original article’s appendix, click on the Details tab of the article online. Gidwani-Marszowski R, Needleman J, Mor V, Faricy-Anderson K, Boothroyd DB, Hsin Get al. Quality of end-of-life care is higher in the VA compared to care paid for by traditional Medicare. Health Aff (Millwood). 2018;37(1):95–103. Go to the article, Google Scholar 2 Trivedi AN, Matula S, Miake-Lye I, Glassman PA, Shekelle P, Asch S. Systematic review: comparison of the quality of medical care in Veterans Affairs and non–Veterans Affairs settings. Med Care. 2011;49(1):76–88. Crossref, Medline, Google Scholar 3 Weeks WB, West AN, Wallace AE, Lee RE, Goodman DC, Dimick JBet al. Reducing avoidable deaths among veterans: directing private-sector surgical care to high-performance hospitals. Am J Public Health 2007;97(12):2190–1. Crossref, Google Scholar Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 2 April 2018 Information© 2018 Project HOPE—The People-to-People Health Foundation, Inc.PDF download

Discrete-choice experiment to analyse preferences for centralizing specialist cancer surgery services

BackgroundCentralizing specialist cancer surgery services aims to reduce variations in quality of care and improve patient outcomes, but increases travel demands on patients and families. This study aimed to evaluate preferences of patients, health professionals and members of the public for the characteristics associated with centralization.MethodsA discrete‐choice experiment was conducted, using paper and electronic surveys. Participants comprised: former and current patients (at any stage of treatment) with prostate, bladder, kidney or oesophagogastric cancer who previously participated in the National Cancer Patient Experience Survey; health professionals with experience of cancer care (11 types including surgeons, nurses and oncologists); and members of the public. Choice scenarios were based on the following attributes: travel time to hospital, risk of serious complications, risk of death, annual number of operations at the centre, access to a specialist multidisciplinary team (MDT) and specialist surgeon cover after surgery.ResultsResponses were obtained from 444 individuals (206 patients, 111 health professionals and 127 members of the public). The response rate was 52·8 per cent for the patient sample; it was unknown for the other groups as the survey was distributed via multiple overlapping methods. Preferences were particularly influenced by risk of complications, risk of death and access to a specialist MDT. Participants were willing to travel, on average, 75 min longer in order to reduce their risk of complications by 1 per cent, and over 5 h longer to reduce risk of death by 1 per cent. Findings were similar across groups.ConclusionRespondents' preferences in this selected sample were consistent with centralization.

Measuring and improving comprehensive pediatric cardiac care: Learning from continuous quality improvement methods and tools

Quality improvement (QI) is becoming a central part of the work of clinicians throughout healthcare. Continuous quality improvement (CQI), Lean Management Systems (LMS) and Lean Six Sigma (LSS) are management philosophies as well as management methods. They offer an approach, a set of tools, and a way of thinking about how to more effectively assess and study clinical flow, including addressing variation in clinical process and operations. We define CQI as the daily use of QI methods as a regular part of practice engaging all practice staff, constantly measuring structure, processes, outcomes against effective practices (benchmarking), moving from one QI project to the next, pursuing the goal of “The right care for every child every time”. It is based on clear scientific principles, a valid way of measuring change and has theories of reliability and human factors that underpin the interventions.Significant variations in quality of care provided to pediatric patients leading to substandard care have been well documented. For example, in antibiotic prescribing for community acquired pneumonia; pediatric secondhand smoke reduction; screening for diabetes in cystic fibrosis program; and, in depression screening in Type 1 Diabetes. Despite this, not enough pediatric practices are performing continuous quality improvement (CQI) as part of their daily activities.All health care professionals caring for children should consider incorporating quality measurement into their practice. However, we need to focus on what is the right approach to take and the right questions to ask and address the challenges of aggregating scientifically imperfect tests of change. Increasingly, colleagues, patients, payers and certifying agencies expect such measurement to achieve the Triple Aim of better health, better care and lower cost. In addition, new payment models increasingly pay providers for demonstrated value rather than volume, and they expect participation in continuous improvement. Quality Improvement (QI) is a critical component of the American Board of Pediatrics (ABP) Maintenance of Certification (MOC) Part 4. This requires pediatricians to participate in a meaningful manner in two data-driven QI projects every five years. Pediatricians can select quality measures to evaluate whether patient outcomes and experience improve, and if not, identify and overcome barriers. In this paper we discuss performance improvement using CQI and related methods, suggest approaches to help pediatric cardiologists to ask the right questions when seeking to drive improvement, and consider the implications of measurement theory and complexity science for QI and CQI.

Organizational, Regional, and Community Factors Determining Protocol Compliance for Patients With Acute Myocardial Infarction.

This study examined factors determining hospital compliance to Hospital Quality Alliance's protocol for patients with myocardial infarction. Using a spatially matched sample of 132 Magnet and 264 non-Magnet hospitals, multivariate regressions determined significant hospital characteristics associated with compliance per Hospital Quality Alliance protocol. Adherence to the Hospital Quality Alliance protocols varied widely by hospital characteristics. Registered nurse staffing/bed was a key factor determining patient care quality variation. Quality of care practices such as protocol compliance should be measured and examined separately.

Geographic Region and Profit Status Drive Variation in Hospital Readmission Outcomes Among Inpatient Rehabilitation Facilities in the United States

ObjectiveTo examine whether there are differences in inpatient rehabilitation facilities' (IRFs') all-cause 30-day postdischarge hospital readmission rates vary by organizational characteristics and geographic regions. DesignObservational study. SettingIRFs. ParticipantsMedicare fee-for-service beneficiaries discharged from all IRFs nationally in 2013 and 2014 (N = 1166 IRFs). InterventionsNot applicable. Main Outcome MeasuresWe applied specifications for an existing quality measure adopted by Centers for Medicare & Medicaid Services for public reporting that assesses all-cause unplanned hospital readmission measure for 30 days postdischarge from inpatient rehabilitation. We estimated facility-level observed and risk-standardized readmission rates and then examined variation by several organizational characteristics (facility type, profit status, teaching status, proportion of low-income patients, size) and geographic factors (rural/urban, census division, state). ResultsIRFs’ mean risk-standardized hospital readmission rate was 13.00%±0.77%. After controlling for organizational characteristics and practice patterns, we found substantial variation in IRFs' readmission rates: for-profit IRFs had significantly higher readmission rates than did not-for-profit IRFs (P<.001). We also found geographic variation: IRFs in the South Atlantic and South Central census regions had the highest hospital readmission rates than did IRFs in New England that had the lowest rates. ConclusionsOur findings point to variation in quality of care as measured by risk-standardized hospital readmission rates after IRF discharge. Thus, monitoring of readmission outcomes is important to encourage quality improvement in discharge care planning, care transitions, and follow-up.

Molecular Tumor Boards: current practice and future needs

BackgroundDue to rapid technical advances, steeply declining sequencing costs, and the ever-increasing number of targeted therapies, it can be expected that extensive tumor sequencing such as whole-exome and whole-genome sequencing will soon be applied in standard care. Clinicians will thus be confronted with increasingly complex genetic information and multiple test-platforms to choose from. General medical training, meanwhile, can hardly keep up with the pace of innovation. Consequently, there is a rapidly growing gap between clinical knowledge and genetic potential in cancer care. Multidisciplinary Molecular Tumor Boards (MTBs) have been suggested as a means to address this disparity, but shared experiences are scarce in literature and no quality requirements or guidelines have been published to date. MethodsBased on literature review, a survey among hospitals in The Netherlands, and our own experience with the establishment of a nationally operating MTB, this article evaluates current knowledge and unmet needs and lays out a strategy for successful MTB implementation. ResultsHaving access to an MTB can improve and increase the application of genetics-guided cancer care. In our survey, however, <50% of hospitals and only 5% of nonacademic hospitals had access to an MTB. In addition, current MTBs vary widely in terms of composition, tasks, tools, and workflow. This may not only lead to variation in quality of care but also hinders data sharing and thus creation of an effective learning community. ConclusionsThis article acknowledges a leading role for MTBs to govern (extensive) tumor sequencing into daily practice and proposes three basic necessities for successful MTB implementation: (i) global harmonization in cancer sequencing practices and procedures, (ii) minimal member and operational requirements, and (iii) an appropriate unsolicited findings policy. Meeting these prerequisites would not only optimize MTB functioning but also improve general interpretation and application of genomics-guided cancer care.

Quality of care indicators in inflammatory bowel disease in a tertiary referral center with open access and objective assessment policies

BackgroundIn the management of inflammatory bowel diseases, there is considerable variation in quality of care. AimsThe aim of this study was to evaluate structural, access/process components and outcome quality indicators in our tertiary referral IBD center. MethodsIn the first phase, structural/process components were assessed, followed by the second phase of formal evaluation of access and management on a set of consecutive IBD patients with and without active disease (248CD/125UC patients, median age 35/39 years). ResultsStructural/process components of our IBD center met the international recommendations. At or around the time of diagnosis usual procedures were full colonoscopy in all patients, with ileocolonoscopy/gastroscopy/CT/MRI in 81.8/45.5/66.1/49.6% of CD patients. A total of 86.7% of CD patients had any follow-up imaging evaluation or endoscopy. The median waiting time for non-emergency endoscopy/CT/MRI was 16/14/22 days. During the observational period patients with flares (CD/UC:50.6/54.6%) were seen by specialist at the IBD clinic within a median of 1day with same day laboratory assessment, abdominal US, CT scan/surgical consult and change in therapy if needed. Surgery and hospitalization rates were 20.1/1.4% and 17.3/3.2% of CD/UC patients. ConclusionOur results highlight that structural components and processes applied in our center are in line with international recommendations, including an open clinic concept and fast track access to specialist consultation, endoscopy and imaging.

Impaired renal function affects clinical outcomes and management of patients with heart failure.

AimsInpatients with heart failure and renal impairment have poor outcomes and variable quality of care. We investigate treatment practice and outcomes in an unselected real‐world cohort using historical creatinine measurements.Methods and resultsAdmissions between 1/4/2013 and 30/4/2015 diagnosed at discharge with heart failure were retrospectively analysed. Stages of chronic kidney disease (CKD) and acute kidney injury (AKI) were calculated from creatinine at discharge and 3–12 months before admission. We identified 1056 admissions of 851 patients (mean age 76 years, 56% Caucasian, 36% with diabetes mellitus, 54% with ischaemic heart disease, and 57% with valvular heart disease). CKD was common; 36%—Stage 3a/b, 11%—Stage 4/5; patients were older, more often diabetic, with higher potassium, lower haemoglobin, and more oedema but similar prevalence of left ventricular systolic dysfunction (LVSD) compared patients with Stages 0–2. AKI was present in 17.0% (10.4%—Stage 1, 3.7%—Stage 2, and 2.9%—Stage 3); these had higher potassium and lower haemoglobin than patients with no AKI. Length of stay was longer in Stage 4/5 CKD [11 days; P = 0.008] and AKI [13 days; P = 0.006]. Mortality was higher with Stage 4/5 CKD (13.8% compared with 7.7% for Stages 0–2 CKD (P = 0.036)] and increased with AKI (5%—no AKI, 20.9%—Stage 1, 35.9%—Stage 2, and 48.4%—Stage 3; P < 0.001). Adjusted for age, diabetes, and LVSD, both AKI and Stage 4/5 CKD were independent predictors of in‐hospital mortality. In survivors with LVSD, the discharge prescription of angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers decreased with progressive CKD, [84%—no‐mild, 59%—moderate, and 36%—severe CKD; P < 0.001]; this was not purely explained by hyperkalaemia.ConclusionsInpatients with heart failure and renal impairment, acute and chronic, failed to receive recommended therapy and had poor outcomes.

Racial/Ethnic Disparity in NICU Quality of Care Delivery.

Differences in NICU quality of care provided to very low birth weight (<1500 g) infants may contribute to the persistence of racial and/or ethnic disparity. An examination of such disparities in a population-based sample across multiple dimensions of care and outcomes is lacking. Prospective observational analysis of 18 616 very low birth weight infants in 134 California NICUs between January 1, 2010, and December 31, 2014. We assessed quality of care via the Baby-MONITOR, a composite indicator consisting of 9 process and outcome measures of quality. For each NICU, we calculated a risk-adjusted composite and individual component quality score for each race and/or ethnicity. We standardized each score to the overall population to compare quality of care between and within NICUs. We found clinically and statistically significant racial and/or ethnic variation in quality of care between NICUs as well as within NICUs. Composite quality scores ranged by 5.26 standard units (range: -2.30 to 2.96). Adjustment of Baby-MONITOR scores by race and/or ethnicity had only minimal effect on comparative assessments of NICU performance. Among subcomponents of the Baby-MONITOR, non-Hispanic white infants scored higher on measures of process compared with African Americans and Hispanics. Compared with whites, African Americans scored higher on measures of outcome; Hispanics scored lower on 7 of the 9 Baby-MONITOR subcomponents. Significant racial and/or ethnic variation in quality of care exists between and within NICUs. Providing feedback of disparity scores to NICUs could serve as an important starting point for promoting improvement and reducing disparities.

Predictors, Quality Markers, and Economics of Volunteering Internationally: Results from a Comprehensive Survey of American Society of Plastic Surgeons Members.

Plastic surgeons have a long history of international volunteer work. To date, there have been no outcome-based studies among surgeons who volunteer internationally. The purpose of this study was to describe predictors of volunteering, clinical quality markers, and economics of international volunteering among American plastic surgeons. A cross-sectional validated e-mail survey tool was sent to all board-certified plastic surgeons by the American Society of Plastic Surgeons. The survey response rate was 15 percent (745 total individuals), of which 283 respondents traveled within the past 5 years. Analysis was performed in R. Stepwise multivariate logistic regression was performed to determine the predictors of death/complication. Respondents reported high use of medical records, follow-up care, and host affiliation. Fewer than half of all respondents reported use of international safety surgery guidelines, and the majority of respondents reported volunteering abroad outside of their scope of practice. The majority of children younger than 5 years were not cared for by a pediatric anesthesiologist. The majority of participants reported personally spending more than $1000 on their last trip and performing surgery estimated to be worth on average $28,000 each. International surgical volunteer trips attempt to ease the global burden of surgical disease. The authors' study reports variation in quality of care provided on these trips. Most significantly, the majority of children younger than 5 years were not cared for by a pediatric anesthesiologist, and many plastic surgeons operated outside of their scope of practice.

Effect of a model consultation informed by guidelines on recorded quality of care of osteoarthritis (MOSAICS): a cluster randomised controlled trial in primary care.

SummaryObjectiveTo determine the effect of a model osteoarthritis (OA) consultation (MOAC) informed by National Institute for Health and Care Excellence (NICE) recommendations compared with usual care on recorded quality of care of clinical OA in general practice.DesignTwo-arm cluster randomised controlled trial.SettingEight general practices in Cheshire, Shropshire, or Staffordshire UK.ParticipantsGeneral practitioners and nurses with patients consulting with clinical OA.InterventionFollowing six-month baseline period practices were randomised to intervention (n = 4) or usual care (n = 4). Intervention practices delivered MOAC (enhanced initial GP consultation, nurse-led clinic, OA guidebook) to patients aged ≥45 years consulting with clinical OA. An electronic (e-)template for consultations was used in all practices to record OA quality care indicators.OutcomesQuality of OA care over six months recorded in the medical record.Results1851 patients consulted in baseline period (1015 intervention; 836 control); 1960 consulted following randomisation (1118 intervention; 842 control). At baseline wide variations in quality of care were noted. Post-randomisation increases were found for written advice on OA (4–28%), exercise (4–22%) and weight loss (1–15%) in intervention practices but not controls (1–3%). Intervention practices were more likely to refer to physiotherapy (10% vs 2%, odds ratio 5.30; 95% CI 2.11, 13.34), and prescribe paracetamol (22% vs 14%, 1.74; 95% CI 1.27, 2.38).ConclusionsThe intervention did not improve all aspects of care but increased core NICE recommendations of written advice on OA, exercise and weight management. There remains a need to reduce variation and uniformly enhance improvement in recorded OA care.Trial registration numberISRCTN06984617.

The relationship between physician burnout and quality of healthcare in terms of safety and acceptability: a systematic review

ObjectivesThis study reviews the current state of the published peer-reviewed literature related to physician burnout and two quality of care dimensions. The purpose of this systematic literature review is to...

Variation in quality of primary-care services in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania.

ObjectiveTo analyse factors affecting variations in the observed quality of antenatal and sick-child care in primary-care facilities in seven African countries.MethodsWe pooled nationally representative data from service provision assessment surveys of health facilities in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania (survey year range: 2006–2014). Based on World Health Organization protocols, we created indices of process quality for antenatal care (first visits) and for sick-child visits. We assessed national, facility, provider and patient factors that might explain variations in quality of care, using separate multilevel regression models of quality for each service.FindingsData were available for 2594 and 11 402 observations of clinical consultations for antenatal care and sick children, respectively. Overall, health-care providers performed a mean of 62.2% (interquartile range, IQR: 50.0 to 75.0) of eight recommended antenatal care actions and 54.5% (IQR: 33.3 to 66.7) of nine sick-child care actions at observed visits. Quality of antenatal care was higher in better-staffed and -equipped facilities and lower for physicians and clinical officers than nurses. Experienced providers and those in better-managed facilities provided higher quality sick-child care, with no differences between physicians and nurses or between better- and less-equipped clinics. Private facilities outperformed public facilities. Country differences were more influential in explaining variance in quality than all other factors combined.ConclusionThe quality of two essential primary-care services for women and children was weak and varied across and within the countries. Analysis of reasons for variations in quality could identify strategies for improving care.

How rural and urban patients in Australia with colorectal or breast cancer experience choice of treatment provider: A qualitative study

Modern healthcare systems promote patient choice of cancer treatment provider, but little is known about how place of residence influences decision-making. This research explored how rural and urban patients with breast or colorectal cancer experience choice of cancer treatment provider in Victoria, Australia. Realist thematic analysis of 43 semi-structured telephone interviews identified little active participation in decision-making regardless of area of residence or cancer diagnosis. Perceptions of choice were impacted by urgency for treatment, insurance status and access to providers, a key issue for rural patients. All patients wanted high quality care, but needed to trust health professional's recommendations. Rural patients experienced more complex decision-making, balancing a range of social factors with perceptions about quality of accessible care. Further research into variation in quality of care and complex cancer pathways for rural and urban cancer patients is warranted to inform choices and enhance patient-centred care.

Abstract 183: Effect of Statin in Acute Cardioembolic Stroke Patients Who Are not Indicated According to Current Guidelines

Background: There is no specific recommendation on statin therapy for cardioembolic stroke (CES) patients in current stroke guidelines. We evaluated the effect of statin on major vascular events following acute ischemic stroke in patients with CES and no other indications for statin. Methods: Using a prospective multicenter stroke registry database, we identified acute ischemic stroke patients who were hospitalized between 2008 and 2015 and were categorized into CES according to the Trial of Org 10172 in Acute Stroke Treatment classification. Patients who had established indications for statin in accordance with the recent stroke guidelines were excluded. Primary outcome measure was a major vascular event, a composite of stroke recurrence, myocardial infarction and vascular death; and secondary outcome measures were stroke recurrence and all-cause death. We performed frailty model analysis to estimate hazard ratios (HRs) of statin therapy on outcomes accounting for variation in quality of care among centers. Stabilized inverse probability of treatment weighting method with propensity scores was used to remove baseline imbalances between statin users and non-users. Results: Of the 6124 CES patients, 2987 patients (male, 52%; mean age, 73±12 years) met the eligibility criteria; and 2125 (71%) of 2987 patients were on statin at discharge. Compared to the non-users, the statin users were more likely to arrive at hospitals later, have milder neurologic deficits at presentation, be on stain prior to index stroke and have hyperlipidemia and were less likely to have atrial fibrillation and occlusion of relevant cerebral arteries. During the median follow-up of 364 days, major vascular events were observed in 118 patients (5.6%) among the statin users and 177 patients (20.5%) among the non-users, respectively (p&lt;0.001 on log rank test); the adjusted HR of statin therapy was 0.35 (95% confidence interval, 0.27-0.46). The adjusted HRs of statin therapy were 0.71 (0.49-1.04) for stroke recurrence and 0.55 (0.46-0.66) for all-cause death, respectively. Conclusion: This study suggests that statin therapy may reduce major vascular events and all-cause death in cardioembolic stroke patients without definite indications for statin.

Factors that influence clinicians’ decisions to offer intravenous alteplase in acute ischemic stroke patients with uncertain treatment indication: Results of a discrete choice experiment

Background Treatment with intravenous alteplase for eligible patients with acute ischemic stroke is underused, with variation in treatment rates across the UK. This study sought to elucidate factors influencing variation in clinicians' decision-making about this thrombolytic treatment. Methods A discrete choice experiment using hypothetical patient vignettes framed around areas of clinical uncertainty was conducted with UK-based clinicians. Mixed logit regression analyses were conducted on the data. Results A total of 138 clinicians completed the discrete choice experiment. Seven patient factors were individually predictive of increased likelihood of immediately offering IV alteplase (compared to reference levels in brackets): stroke onset time 2 h 30 min [50 min]; pre-stroke dependency mRS 3 [mRS 4]; systolic blood pressure 185 mm/Hg [140 mm/Hg]; stroke severity scores of NIHSS 5 without aphasia, NIHSS 14 and NIHSS 23 [NIHSS 2 without aphasia]; age 85 [68]; Afro-Caribbean [white]. Factors predictive of withholding treatment with IV alteplase were: age 95 [68]; stroke onset time of 4 h 15 min [50 min]; severe dementia [no memory problems]; SBP 200 mm/Hg [140 mm/Hg]. Three clinician-related factors were predictive of an increased likelihood of offering IV alteplase (perceived robustness of the evidence for IV alteplase; thrombolyzing more patients in the past 12 months; and high discomfort with uncertainty) and one with a decreased likelihood (high clinician comfort with treating patients outside the licensing criteria). Conclusions Both patient- and clinician-related factors have a major influence on the use of alteplase to treat patients with acute ischemic stroke. Clinicians' views of the evidence, comfort with uncertainty and treating patients outside the license criteria are important factors to address in programs that seek to reduce variation in care quality regarding treatment with IV alteplase. Further research is needed to further understand the differences in clinical decision-making about treating patients with acute ischemic stroke with IV alteplase.

The Experience of Transitional Care for Non-Medically Complex Older Adults and Their Family Caregivers

Transitional care research has mainly focused on the experiences of older adults with complex medical conditions. To date, few publications examine the experience of transitional care for non-medically complex older adults. In this article, we draw on and thematically analyze interview and audio-diary data collected at three hospitals in Eastern England, and we explore the experience of transitional care of 18 older adults and family caregivers. Participants reported mixed experiences when describing their care transitions, which indicated variations in care quality. To achieve independence and overcome the difficulties with care transitions, participants used a range of interrogative techniques, such as questioning and information seeking. We contend that the existing transitional care interventions are inappropriate to address the care needs of non-medically complex older adults and family caregivers. Implications for frontline health care staff and health services researchers are discussed.