International Journal for Quality in Health Care最新文献

Background: Benchmark is 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 the 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 LTCS characteristics associated with ABC attainment.

Results: 2746 LTCS and 244 419 residents (≥65 years) between 1 January 2019 and 31 December 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 hospitalizations (0.1%), pressure injuries (0.2%), delirium and dementia hospitalizations (0.2%), 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 (3.9%), and emergency department presentations (5.1%) were between 1 and 5% and attained by 7-11% of LTCS. The ABC for antipsychotic use (10.5%), chronic opioid use (12.6%), high sedative load exposure (26.8%), and antibiotic use (47.8%) were between 10 and 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: High-quality discharge information is important to promote patient safety when patients are transferred from hospital to primary care. Patients with multiple long-term conditions are especially vulnerable to insufficient transfer of medication information, as they use many medications and have complex interactions with the healthcare services. The aim of this study was to investigate the effect of integrated medicines management provided to hospitalized multimorbid patients on the quality of the discharge medication information.

Methods: Multimorbid patients ≥18 years, using a minimum of four regular medications from a minimum of two therapeutic medication classes were recruited from the Internal Medicine ward, Oslo University Hospital, Norway, from August 2014 to March 2016 and randomly assigned, 1:1, to the intervention or control group. Intervention patients received integrated medicines management throughout the hospital stay. Control patients received standard care. This paper reports the results of a prespecified secondary endpoint analysis of the randomized controlled trial; the difference between the intervention and control group in the quality of discharge medication information.

Results: The analysis population comprised 384 patients. Integrated medicines management improved the discharge summary quality score of the medication information from 5.8 ± 1.5 to 8.6 ± 2.6 [mean difference 2.7, 95% confidence interval (CI) 2.3-3.2, P < .001]. In total, 171 intervention patients (89%) received a patient discharge information letter, compared to 66 control patients (35%), P < .001. The quality score of the medication information in the patient discharge information letter was improved from 6.0 ± 1.8 in the control group to 10.0 ± 1.3 in the intervention group (mean difference 4.0, 95% CI 3.6-4.4, P < .001).

Conclusion: Integrated medicines management delivered to multimorbid patients during a hospital stay improved the quality of the medication information in discharge summaries as well as patient discharge information letters and ensured that a discharge information letter in lay language was prepared for almost all patients who were involved in the management of their medications after discharge.

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 FDTE, propose strategies for improvement, and enhance both team effectiveness and service quality.

Methods: The literature review, key informant interviews, expert consultation, and questionnaire survey were employed. The questionnaire, based on the input-mediator-output-input model, was designed to measure 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 model (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 < .01), goals and systems (β = 0.165, P < .01), cooperative attitude (β = 0.123, P < .05), team behavioral process (β = 0.161, P < .001), and team emotional process (β = 0.193, P < .001). SEM analysis revealed that team input factors, member input factors, and team behavioral process had direct and indirect effects on team effectiveness, while the 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: 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: Iron deficiency is the leading cause of anaemia worldwide and is increasingly treated with intravenous (IV) iron therapy. Staining from IV iron therapy is a rare but significant and preventable adverse event. To mitigate patient harm, a health-service-wide quality improvement project was implemented. This study aimed to determine the real-world impact of a quality improvement project on IV iron staining incidents and preventability.

Methods: A retrospective chart audit was undertaken for all IV iron staining episodes reported in a directorate-wide clinical incident reporting database (RiskMan) between 2016 and 2022. Incidence rates of IV iron staining, preventability, and stain severity were compared pre- and post-implementation of a standardized IV iron procedure.

Results: Over 7 years, 103 IV iron stains were identified, resulting in a staining rate of 0.31 stains per 100 infusions (pre 0.27% and post 0.34%, P = .25). Implementation of the standardized IV iron procedure resulted in improvements in pharmacist review of the medication order (61.8% versus 89.7%, P < .01), use of the statewide IV iron infusion consent form (27.3% versus 76.9%, P < .01), and appropriate cannula site (14.3% versus 52.5%, P < .01). Smaller stain sizes were associated with cessation of the infusion at identification of extravasation (312 cm2 versus 35 cm2) (P = .04). Preventability was assigned to 86% of stains.

Conclusion: The incidence rate of IV iron staining in a real-world clinical setting is 0.31%. There was increased compliance with several best practice principles and 86% of stains were preventable. Early identification and intervention of potential staining incidents results in smaller iron stains for patients. Quality improvement tools developed for this project can contribute to patient outcomes internationally.