Quality Management in Health Care最新文献

Background and objectives: The Transforming Clinical Practices Initiative (TCPI) was a 4-year, large-scale, collaborative, peer-based learning initiative for physician practices of all specialties with broad goals to improve the quality of patient care, spend health care dollars more wisely, and assist practices in being ready to succeed under value-based payment (VBP). We investigated whether the COVID-19 pandemic had erased or diminished practice transformation progress made during the TCPI program period, through a follow-up survey of participating practices fielded in October 2021.

Methods: In October 2021 to April 2022, we surveyed a probability sample of 2207 primary care and specialty practices that participated in the TCPI, receiving 610 responses. We asked about practice characteristics, financial and ownership stability, clinical performance, and quality improvement efforts, both now and prior to COVID-19. The COVID-19 content was part of a larger survey. Responses were weighted to account for sample selection, unknown eligibility status, and nonresponse. We generated weighted univariate descriptive statistics representative of practices with clinicians enrolled in TCPI. These estimated percentages have a 95% confidence interval of about ±5%. Multivariate analysis of unweighted data examined associations between practice characteristics and other variables of interest.

Results: For all but one of 13 practice transformation activities engaged in prior to the COVID-19 public health emergency, a majority of practices (at least 52%) reported that the progress on these activities were either not hurt or were helped by their COVID-19 experience. Compared to January 2020, only about 7% of practices reported that their quality of care or clinical performance was worse due to COVID-19, and 32% reported that their quality of care was better. More rural than urban practices reported that half or more of their transformation activities were hurt by COVID-19 (29% and 14%, respectively). Physician-owned practices were more likely to report quality is better today than prior to COVID-19 relative to practices with other ownership types such as hospitals or health systems (43% vs 24%).

Conclusions: Most practices have been able to recover from the deep stress of the COVID-19 pandemic and continue their efforts to improve patient care and performance to succeed under VBP. These results suggest a high perceived return on investment in value-readiness support along with emergency financial support in times of crisis, as well as room to continue preparation for any future pandemic and the national movement toward increased VBP, especially in rural settings.

Background and objective: Central Line-Associated Bloodstream Infection (CLABSI) remains a leading cause of death among critically ill patients. Implementing preventive measures and adhering to best practices is a crucial action to proactively prevent its occurrence. This project aimed to reduce the overall CLABSIs rate in adult medical/surgical Intensive Care Units (ICUs) of hospitals under the Ministry of Defense Health Services (MODHS) in Saudi Arabia. The baseline CLABSI rate was 2 cases per 1000 catheter days during the first quarter of 2020, while the target was to achieve a rate equal to or lower than 0.8 as reported by the American National Healthcare Safety Network (NHSN) in 2013.

Methods: The initiative was carried out across 15 hospitals under the purview of MODHS. Data on CLABSI incidents were collected from the ICUs dedicated to adult medical and surgical care. The project utilized the Institute for Healthcare Improvement collaborative model to achieve breakthrough improvement in a short-term learning system that facilitated the collaboration of participating hospitals in the pursuit of enhancements in CLABSI rates. The project involved 3 cycles, each consisting of a learning session followed by an action period.

Results: The data revealed a continuous improvement in the overall CLABSI rate within MODHS hospitals, progressing positively for 4 consecutive quarters and attaining a value of 0.3 during the third quarter of 2021. This signifies an impressive 85% reduction from the initial baseline of 2, and the rate remains below the project benchmark of 0.8.

Conclusion: The project successfully employed collaborative learning cycles, fostering effective knowledge-sharing among teams and promoting active engagement. This approach proved instrumental in achieving learning objectives, identifying gaps, and determining appropriate courses of action. Key factors for the project's success included standardizing the change package, conducting regular training sessions, encouraging open discussions, and sharing experiences.

Background and objectives: To establish whether posters displayed across the walls on hospital wards are read, what information is important, and how the information should be received.

Methods: Sixty-eight staff and 32 patients' relatives were interviewed across 3 older people's medical wards followed by 20 follow-up secondary questionnaires postintervention.

Results: Only 23% of those interviewed were able to recall any of the posters displayed, and of those, 34% did not find the information useful. Those interviewed were enthusiastic about utilizing alternative media. A quarter felt the walls across the hospitals wards should be for artwork. Among patients' relatives interviewed, common information requests were "the discharge pathway," "delirium," and "falls." Based on the initial findings, a targeted information board was installed and a mural was painted across the wall in one of the wards. Further post-intervention interviews with patients' relatives showed that the board was well received, but further unmet information needs were uncovered. Despite the new mural, 45% called for more paintings.

Conclusions: Most people ignore the posters displayed across the walls of hospital wards, and unmet information needs are rife. An appetite exists for alternative media. Paintings were earnestly called for, highlighting how a comforting environment could be part of the holistic care we offer patients in hospital.

Background and objectives: Managers in health care today face an array of digital technologies that assist or augment certain human tasks. But these technologies are often fraught and present challenges to managers, whose competencies must evolve to keep pace with technological advancements.

Methods: Drawing on theory about technology, work, and organizations, we present a human-technology continuum to facilitate this discussion for managers. Furthermore, we illustrate how managerial competencies are linked to the entire human-technology continuum, rather than to specific technologies, using diabetes management examples.

Results: The human-technology continuum indicates that augmentative technologies are layered onto assistive ones in health care settings. This suggests that technological advancements not only enhance but alter managerial competencies.

Conclusions: Digital technology stretches the boundaries of managers' day-to-day work in health care. Therefore, we make the following suggestions so the managers can be responsive to ongoing digital transformations: restructuring work, training the workforce, neutralizing threats, establishing ethical boundaries, and building partnerships.

Background and objectives: The U.S. Preventive Services Task Force (USPSTF) does not currently recommend routine screening for kidney cancer, even though approximately 14 390 people are expected to die from this disease in the United States in 2024. Individualized risk-based kidney cancer screening offers the potential to effectively detect cancer at an early stage and avoid unnecessarily screening the rest of the population who are at low risk. This study proposes electronic health records (EHR) risk evaluation for kidney cancer by examining a comprehensive set of medical history including diagnoses, comorbidities, viruses, and rare diseases.

Methods: The relevant medical history for predicting kidney cancer occurrence was identified from the analysis of All of Us data in three steps. First, a Systematized Nomenclature of Medicine (SNOMED) code binary indicator variable in EHR was set for the presence of kidney cancer. Second, the relationship between this binary indicator of cancer and all prior health conditions was examined using the Strong Rule for Feature Elimination and Least Absolute Shrinkage and Selection Operator logistic regression methods of variable selection. Third, the accuracy of the model was reported using cross-validated McFadden's R2 and Area under the Receiver Operating Characteristic curve (AROC) values.

Results: The analysis identified 133 out of an initial set of 25 683 clinical diagnoses (represented by SNOMED codes) that were predictive of kidney cancer. The model achieved a cross-validated McFadden's R2 of 0.195 and an AROC of 0.799. Most of the identified codes are consistent with the known risk factors for kidney cancer.

Conclusions: It is possible to accurately predict the risk of kidney cancer from medical history using this method. Additional studies to establish high-dimensional predictive risk factors are needed to see if EHR personalized risk prediction can lead to cost-effective cancer screening and eventually better clinical outcomes.

Background and objectives: We evaluated the prevalence of potential reinforcement of common unhealthy misinterpretations of bodily sensations in social media (YouTube videos) addressing elbow enthesopathy (eECRB, enthesopathy of the extensor carpi radialis brevis, tennis elbow).

Methods: We recorded video metric data on 139 unique YouTube videos when searching "lateral epicondylitis" and "tennis elbow." We designed a rubric to assess the level of potential reinforcement of unhelpful thinking in videos about eECRB. Informational quality was scored with an adapted version of the DISCERN instrument. We then assessed the factors associated with these scores.

Results: Sixty-five percent (91 of 139) of videos contained information reinforcing at least one common misconception regarding eECRB. Potential reinforcement of misconceptions was associated with longer video duration, higher likes per day, and higher likes per view. No factors were associated with information quality scores.

Conclusions: These findings of a high prevalence of potential reinforcement of misconceptions in YouTube videos, in combination with the known associations of misconceptions with greater discomfort and incapability, point to the potential of such videos to harm health. Producers of patient facing health material can add avoidance of reinforcement of unhelpful thinking along with readability, accuracy, and relevance as a guiding principle.

Background and objectives: Women of reproductive age with substance use (SU) disorders have lower rates of contraceptive use and higher rates of unintended pregnancy than women without SU disorders and are less likely to access treatment than men. Integration of SU and sexual and reproductive health (SRH) services, using a model known as Screening, Brief Intervention, and Referral to Treatment (SBIRT), has been proven effective in reducing SU and improving health care equity. The SBIRT model includes screening, brief intervention (a short client-centered conversation providing an opportunity to identify/discuss concerns), and referral to treatment. The purpose of this study was to test whether an established quality improvement (QI) learning collaborative model could be used to support SU and SRH sites in implementing an SBIRT/SBIRT-like model to improve health outcomes for women. Five SRH sites and 4 SU sites across New York State participated in the Partnership to Advance Integrated Referrals (PAIR), an 18-month QI learning collaborative designed and implemented by Public Health Solutions.

Methods: Six standardized mixed-methods data collection tools were used over 18 months to gather process and outcome data from over 130 QI team members and site staff and over 5000 clients.

Results: By the end of PAIR, QI team members and site staff showed a reduction in bias, increased knowledge and comfort, increased rating of organizational practices related to client-centered care, and increased access to peer learning, information about best practices, and training and technical assistance. SU sites increased SRH screening from 47.9% in the first quarter of data collection to 67.4% in the final quarter and increased brief interventions from 92.5% in the first quarter to 100.0% in the final quarter. Similarly, SRH sites increased SU screening from 51.6% to 75.6% and increased brief interventions from 81.3% to 85.1%. The processes and outcomes were very different for the SU and SRH sites, and their varying successes and challenges are discussed. Making and verifying referrals remained challenging.

Conclusions: The results of PAIR demonstrated the feasibility of SU and SRH sites implementing an SBIRT/SBIRT-like model when supported by a QI learning collaborative. Larger community and organizational challenges (COVID-19, staff turnover) still present barriers to improved reproductive health and SU outcomes for women.

Background and objectives: Malignant brain and other central nervous system tumors (MBT) are the second leading cause of cancer death among males aged 39 years and younger, and the leading cause of cancer death among males and females younger than 20. There are few widely accepted predictors and a lack of United States Preventive Services Taskforce recommendations for MBT. This study examined how medical history could be used to assess the risk of MBT.

Methods: Using over 400,000 patients' medical histories, including nearly 1,800 with MBT, Logistic Least Absolute Shrinkage and Selection Operator (LASSO) regression was used to predict MBT. More than 25,000 diagnoses were grouped into 16 body systems, plus pairwise and triple combinations, as well as indicators for missing values. Data were split into 80/20 training and validation sets with fit and accuracy assessed using McFadden's R2 and the area under the receiver operating characteristic curve (AUC).

Results: Diagnoses of the endocrine, nervous, and lymphatic systems consistently showed greater than three times more association with MBT. The best performing model at an AUC of 0.83 consisted of 14 body system diagnosis groups and pairwise interactions among groups, in addition to demographic, social determinant of health, death, and six missing diagnosis grouping indicators.

Conclusions: This study demonstrated how large data models can predict MBT in patients using EHR data. With the lack of preventive screening guidelines and known risk factors associated with MBT, predictive models provide a universal, non-invasive, and inexpensive method of identifying at-risk patients.