International Journal for Quality in Health Care最新文献

This editorial examines the ongoing challenges associated with developing and implementing clinical practice guidelines (CPGs), sparked by Ng et al.'s analysis of pre-participation physical evaluations (PPE) for youth athletes. The authors reveal that only a third of the PPE evaluation they reviewed documented all essential patient history elements. They suggest that the limited efficacy of PPEs in predicting serious cardiac events may lead practitioners to deprioritize comprehensive history-taking, and point to the stronger evidence for electrocardiograms (ECG) as a more effective diagnostic tool. Practitioners should reflect more broadly on the inherent tension between CPG standardization and the need for clinical flexibility. While standardized guidelines are crucial for consistent, high-quality care in acute and chronic settings, social determinants of health (SDH) can affect patient adherence and outcomes, necessitating tailored approaches, which can account for the disparities in CPG application across different populations and healthcare environments. Complex guidelines can be overwhelming, particularly in under-resourced settings, where they may be impractical or difficult to follow. For these areas, CPGs should account for local infrastructure and healthcare capabilities, potentially substituting advanced diagnostics with enhanced clinical skills. There are additional concerns about CPG development processes, including the variability in expert opinions, the influence of industry funding, and conflicts of interest that may erode trust and compliance. While industry contributions can enhance guideline robustness, transparency and accountability are vital to maintaining the integrity of CPGs. In conclusion, we call for a pragmatic approach to CPG development that balances scientific rigor with adaptability to diverse clinical and resource-limited settings. Addressing these challenges is essential for fostering equitable and effective patient care and enhancing the trustworthiness of CPGs in the global healthcare landscape.

Background: Giant cell arteritis (GCA) can present diagnostic challenges and early diagnosis is crucial due to potential ischemic complications. Recent guidelines suggest that a suspected diagnosis should be confirmed with temporal artery biopsy or imaging, including ultrasound (US). In our Canadian setting, point-of-care temporal artery US was near unavailable, and biopsy remains the standard of care. We hypothesize that launching a fast-track US clinic by rheumatologists may spare the need for a temporal artery biopsy. Therefore, this study aimed to assess the diagnostic performance of US in this newly launched fast-track clinic.

Methods: In this single-center retrospective cross-sectional analysis, 99 visits were identified from the fast-track clinic between January 2020 and July 2022. Each subject had an US according to a standard protocol for suspicion of either new-onset or relapse of GCA. Ultrasonographers were rheumatologists who acquired training on vascular US techniques before launching the clinic. For each patient presenting with suspected new-onset GCA, the pretest probability was calculated using the Southend GCA probability score. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated using the rheumatologist clinical diagnosis as the gold standard for GCA diagnosis.

Results: A total of 22 subjects had a diagnostic of GCA and 77 had another diagnostic. Patients with and without GCA were, respectively, 81.8% versus 72.7% females, had a mean age of 76.6 ± 7.7 versus. 74.8 ± 9.8 years, and a mean CRP of 73.4 ± 57.8 versus 38.3 ± 59.9 mg/l. Temporal artery US demonstrated a sensitivity of 86.3% [95% confidence interval (CI), 65.1-97.1%], a specificity of 90.9% (95% CI, 82.2-6.3%), a PPV of 73.1% (95% CI, 56.8-84.9%), and a NPV of 95.9% (95% CI, 89.0-.5%). 14 patients had a suspicion of relapse and were all correctly identified by the US. Among those with suspicion of new-onset 27, 34 and 24 US were performed for high, intermediate, and low pretest probability of GCA, respectively. The high-risk subgroup demonstrated higher PPV while similar sensitivity/specificity was observed between all three subgroups.

Conclusion: Our results highlight the benefits of US as a key diagnostic tool for GCA, particularly when combined with clinical evaluations. An excellent discriminative ability for diagnosis of GCA was shown in this newly launched clinic suggesting that the role of TAB may need to be redefined. These findings will guide on broader implementation of US programs for GCA.

Background: Safety culture development is essential for patient safety in healthcare institution. Perceptions of patient safety and cultural changes are shown up in patient safety reports, however, were rarely investigated. The aim of this study was to investigate the perception of physicians and to explore the development of safety culture using quantitative content analysis for patient safety reports.

Methods: A retrospective analysis of free descriptions of harmful patient safety reports submitted by physicians was performed. Natural language processing and text analysis were conducted using the 'KH Coder'. A co-occurrence analysis was performed in each period to identify and analyze the safety concepts. The study period was grouped into three for comparison.

Results: The patient safety reports from physicians were collected between April 2004 and March 2020. Of these, 3351 reports were harmful; 839 reports were included in period 1, 1016 reports in period 2, and 1496 reports in period 3. Natural language processing identified 316 307 words in the free descriptions of 3351 reports. We identified seven concepts from the cluster in co-occurrence analysis as follows: 'explanation of adverse event to patients and families,' 'central venous catheter,' 'intraoperative procedure and injury,' 'minimally invasive surgery,' 'life-threatening events,' 'blood loss,' and 'medical emergency team and critical care.' These seven concepts showed significant differences among the three periods, except for 'blood loss'. The 'explanation of adverse event to patients and families' decreased in proportion from 11.3% to 8.8% (p<0.05). The 'central venous catheter' decreased from 17.3% to 11.3% (p<0.01). Meanwhile, 'minimally invasive surgeries' and 'intraoperative procedures' increased from 3.9% to 12.9% (p<0.01) and from 10.8% to 14.6% (p<0.05), respectively. Focusing on patients' events, 'life-threatening events' decreased from 13.0% to 8.1% (p<0.01); however, 'medical emergency teams and critical care' increased from 3.3% to 10.6% (p<0.01).

Conclusion: Free description in patient safety reports is useful for evaluating the safety culture. Co-occurrence analysis revealed multiple concepts of physicians' perceptions. Quantitative content analysis revealed changes in perceptions and attitudes, and a disclosure policy of adverse events and priority of patient care appeared with the development of safety culture.

Background: Team-based delivery of family doctor services is associated with improved patient experiences, better health outcomes, and more efficient healthcare utilization. Team effectiveness is related to the team's output, and family doctor team effectiveness (FDTE) directly impacts the quality and efficiency of contracted family doctor services. We aimed to explore the path and mechanisms influencing family doctor team effectiveness, propose strategies for improvement, and enhance both team effectiveness and service quality.

Methods: The literature review, key informant interviews, expert consultation, and questionnaire survey was employed. The questionnaire, based on the IMOI model, was designed to measure family doctor team effectiveness (FDTE) and its influencing factors. Using stratified random sampling, we distributed the questionnaire to family doctors in both developed and underdeveloped areas of Zhejiang Province, China. We performed hierarchical linear regression analysis to examine the relationship between team effectiveness and influencing factors. Subsequently, we used structural equation modeling (SEM) to explore and validate the relationships and mechanisms of action among "team input factors", "member input factors", "team behavioral process", and "team emotional process" on team effectiveness.

Results: The questionnaire was divided into five main sections: 'team input factors', 'member input factors', 'team behavioral process', 'team emotional process', and 'team effectiveness', with 11 dimensions and 42 items. A total of 508 valid questionnaires were returned. The main factors influencing FDTE are team composition (β=-0.116, P<0.01), goals and systems (β=0.165, P<0.01), cooperative attitude (β=0.123, P<0.05), team behavioral process (β=0.161, P<0.001), and team emotional process (β=0.193, P<0.001). SEM analysis revealed that team input factors, member input factors, and team behavioral process had direct and indirect effects on team effectiveness, while team emotional process had a direct effect.

Conclusions: It is recommended to optimize the basic inputs of family doctor teams, enhance the intrinsic motivation of team members, promote team interaction and cooperation, and foster a positive atmosphere for family doctor teamwork.

Background: The Finnish public healthcare system aims to ensure equal access to health services for all but faces challenges in meeting the demand for specialized care, such as neurosurgery, due to resource constraints. This study investigates interventions to increase resources at a neurosurgery outpatient clinic to improve patient care without compromising waiting times for diagnoses and treatments, leveraging Finland's unique healthcare landscape.

Methods: The study was conducted at Kuopio University Hospital's Department of Neurosurgery, the sole provider of neurosurgical care in Eastern Finland. Two interventions were designed to optimize clinic operations: one focusing on dynamic resource allocation through continuous monitoring and the other on establishing a fixed additional neurosurgeon slot. Process capability and regression analysis were employed to evaluate the effects of these interventions on the number of outpatient visits and the variability in daily patient numbers.

Results: The preliminary analysis showed an average of 9.3 outpatient visits per day (SD 5.2). The introduction of an additional neurosurgeon led to an increase of 5.014 visits per day, according to the regression analysis performed before the interventions. Following the interventions, the clinic observed an increase in the average number of daily outpatient visits to 9.8 after the first intervention and 11.6 after the second, with corresponding improvements in the number of neurosurgeons present. The second intervention, which established a predictable additional resource, resulted in a more significant improvement in process efficiency and stability. After the interventions, the number of new neurosurgical first patient visits increased by 7% (97 patients).

Conclusion: This study demonstrates the importance of structured and predictable resource allocation in enhancing the efficiency of specialized healthcare services, particularly in neurosurgery. It also underscores the potential of planned interventions to manage and improve patient care in a publicly funded healthcare system, despite the challenges posed by limited resources and the need for prioritization. Moreover, the findings highlight the necessity of ongoing measurement and analysis of development projects to ensure sustained improvement and avoid regression in process quality.

Background: Benchmarks are an important aspect of quality measurement and evaluation of long-term care services (LTCS) performance. In this study, we aimed to estimate achievable benchmarks of care (ABC©) for 12 quality indicators used to monitor quality of care in Australian LTCS and to identify LTCS characteristics associated with attaining the estimated ABC.

Methods: A cross-sectional study was conducted using integrated population-based datasets from long-term care, health care, and social welfare sectors within the Registry of Senior Australians (ROSA) National Historical Cohort. All LTCS residents in 2019 were included. Twelve risk-adjusted quality indicators were examined. ABC were defined as the performance level of top-ranked LTCS, including those sequentially from rank 1 onward, until the combined number of residents included at least 10% of all residents nationally. Indicator-specific ABC for 2019 were estimated using Bayesian-adjusted performance fraction ranking. Logistic regressions estimated LCTS characteristics associated with ABC attainment.

Results: 2746 LTCS and 244,419 residents (≥65 years) between 01/01/2019 and 31/12/2019 were included. The cohort was mostly female (65%), with a median age of 86 years, and 56% had dementia. The ABC provide performance targets based on the observed levels of top-performing LTCS. The ABC for premature mortality (0.007%), weight loss hospitalisations (0.1%), pressure injuries (0.2%), delirium and dementia hospitalisations (0.3%), and medication-related adverse events (0.4%) were lower than 1% and attained by 17-59% of LTCS. The ABC for fractures (1.3%), falls (4.0%), and emergency department presentations (5.1%) were between 1-5% and attained by 7-11% of LTCS. The ABC for antipsychotic use (10.7%), chronic opioid use (23.6%), high sedative load exposure (27.4%), and antibiotic use (47.8%) were between 10-50% and met by 6-7% of LTCS. Smaller LTCS and government-owned LTCS were more likely to achieve the ABC compared to medium, larger, private, and not-for-profit LTCS.

Conclusion: This is the first national estimation of ABC for Australian LTCS, identifying real-world examples of LTCS with relatively better national performance. The ABC are realistic goals for LTCS improvement efforts. They can be leveraged as national standards in quality monitoring reports and incentive programs. Smaller and government LTCS were generally more likely to attain ABC.

Background: Healthcare quality has long been defined and assessed using different theories that outline care delivery as a product of two factors; one being the clinical aspect symbolizing the science of care and the other being the non-clinical aspect symbolizing non-medicinal aspect of care delivery. To the best of our knowledge, the joint effect of the clinical, social and technological aspects of care on outcome quality has not been investigated in the literature. The current study empirically investigates the joint effect of the clinical, social and technological care quality dimensions on mortality rates through analyzing longitudinal data from 3081 US hospitals.

Methods: Six-year data from more than 3000 acute care hospitals is analyzed using econometric analysis with two stage least square instrumental variable regression models.

Results: Hospitals that jointly focus on clinical, social and technological care dimensions realize lower mortality rates. Combining clinical quality (CM) with either meaningful use of health information technology (MUHIT) or patient-caregiver interaction (PCI) reduces mortality rates. The lowest mortality rate is realized when hospitals combine CM, PCI and MUHIT.

Conclusion: Our study provides empirical evidence on the importance of combining clinical and non-clinical care measures to reduce mortality rates in hospitals. Our results indicate that hospitals that combine dual quality dimensions, clinical quality with either PCI or MUHIT, can also realize improvement in mortality rates. However, the best outcome can be realized by focusing on the triple quality dimensions (CM, PCI and MUHIT). The study provides pointers to healthcare professionals and policy makers on the impact of non-clinical care on the clinical-mortality link in hospitals.

Background: To determine methods of FOBT de-implementation in acute care practice while summarizing the reasons and contraindications for inappropriate FOBT in acute care settings. Fecal occult blood testing is valuable for colorectal cancer screening in ambulatory settings but is not valuable for diagnostics in acute care with consistent indications for discontinuation as a tradition-based practice.

Methods: We included all English language prospective and retrospective evaluation studies of FOBT use in acute care settings with or without de-implementation interventions and published as original research articles in peer-reviewed journals. A meta-analysis of FOBT positivity was conducted using a random effects model. Quality was assessed using Critical Appraisals Skills Programme criteria.

Results: Of 2,471 abstract/titles screened, 157 full-text articles were reviewed, and 22 articles met inclusion criteria of measuring prevalence or de-implementation of FOBT use in acute care settings. All 22 studies evaluated either FOBT use or de-implementation. Twenty articles reported FOBT positivity, with some illustrating that FOBT results were inconsequential to subsequent endoscopy decisions (n=7, 32%). The included studies represent a publication date range spanning 32 years, with limited documentation of de-implementation strategies. Four published studies described system-level disinvestment to administratively eliminate access to inpatient FOBT orders.

Conclusion: Overall, all studies endorsed that the use of FOBTs in acute care settings results in increased workload and/or cost without diagnostic benefit. Critical appraisal of low-value tradition-based practices such as FOBT use in acute care settings are essential for deploying deliberate and effective de-implementation strategies.