Quality Management in Health Care最新文献

Background and objectives: The magnitude of chronic disease management is a daunting health care problem at the same time when there is a reduction in primary care physicians, making achieving high-quality standards and goals extremely challenging for health care professionals. The research objective for this project was to provide evidence to support the use of clinical nurse specialist (CNS)-led multidisciplinary teams in the outpatient setting to improve quality measures in chronic conditions.

Methods: Patient data were collected from 2019 to 2023 for patients engaging in a multidisciplinary care management program in an outpatient internal medicine office. Pre-post data were collected for weight, body mass index, blood pressure, glucose levels, A1C levels, cholesterol levels, and medical diagnosis. Data were recorded for the first care management patient visit and compared to the most recent care management visit. Four hundred five patient records were included in the study.

Results: Ten of the 11 t-tests evaluated were statistically significant in improving health measures. The only variable that did not emerge significant was HDL.

Conclusions: Because of their education and training, CNSs are the best-suited health professionals to lead a team-based collaborative approach to chronic disease care management and improve quality health outcomes in primary care environments. Patients choosing to participate in care management programs demonstrated significant improvement in their health, therefore reducing risk for health, complications.

Background: Effective communication among health care providers constitutes a critical cornerstone for delivering optimal patient care. However, the achievement of efficient communication within patient care remains a challenge in modern medicine. While traditional paging systems have served as the primary means of communication in health care, they are limited to unidirectional communication. To address these shortcomings, bidirectional models emerged, seeking to enhance communication among health care partners. To foster improved communication, our institution implemented a 2-way secure messaging system, Epic Secure Chat. This introduction, however, occurred without tailored guidance on appropriate use, leading to confusion among health care staff regarding optimal, safe utilization of the new platform.

Methods: Employing a system-wide survey to gather data from various in- and outpatient departments, we sought to comprehend the present state of affairs concerning the usage of this platform. The survey was distributed using a hierarchical email approach, beginning with Tier III Safety Huddle participants and cascading through departmental leadership at our institution. Department leaders further disseminated the survey to a wide range of clinical and administrative staff, including providers, nurses, pharmacists, technicians, and ancillary personnel, to ensure diverse role representation. Open-ended responses were analyzed using thematic analysis. The research team systematically coded and categorized responses to identify key themes, areas of consensus, and divergent viewpoints, enabling the extraction of meaningful insights into the use and perception of Epic Secure Chat.

Results: The majority of survey respondents were physicians or advanced practice providers (56.54%) and nurses (31.78%), reflecting a predominantly clinical user base. Epic Secure Chat was widely used for interdisciplinary care coordination (34.07%) and 2-way communication (23.33%), though over 10% reported minimal use. While many valued its efficiency and ease of use, significant concerns emerged. Safety issues, including inappropriate use for urgent communication and lack of closed-loop messaging, accounted for 46.21% of feedback. Workflow challenges (34.70%) and compliance concerns (6.57%) were also noted. Despite these issues, 12.12% of responses highlighted positive impacts on team communication and workflow efficiency.

Conclusion: These findings may serve as a model for other health care organizations seeking to implement or refine secure messaging systems. As communication technologies continue to evolve, it is essential to balance efficiency with safety, ensuring that tools like Secure Chat enhance rather than hinder clinical care. Continued evaluation and adaptation will be critical to achieving this balance and supporting both provider well-being and patient outcomes.

Background and objectives: We developed a novel web-based application, Provider Minder, for providers to track and monitor stroke risk screening in children with sickle cell anemia. Here, we describe the development of the application, the process evaluation during implementation, and our lessons learned.

Methods: An iterative development process was used to develop the Provider Minder application and its functionalities. For our process evaluation, our team conducted surveys and interviews with study teams across 13 sites that used Provider Minder as part of a multi-intervention trial for the Dissemination and Implementation of Stroke Prevention Looking at the Care Environment study. Surveys and interviews were conducted with providers and coordinators at midpoint (1 year) and end point (2 years). Results were integrated and organized according to themes.

Results: The process evaluation indicated factors critical for implementation success, such as coordination across stakeholders. Successes of the intervention included high adaptability for unique site needs, ease of use, low costs of implementation, and perceived effectiveness at capturing missed screenings. Key challenges were the time burden for use, redundancy of data capture, and lack of integration, as Provider Minder was distinct from the electronic medical record.

Conclusions: While providers and coordinators described multiple barriers to implementing Provider Minder, results indicated that perceived successes outweighed barriers. Future efforts to reduce the burden associated with health care complexity and improvement in interoperability of electronic medical records will be important for improving the success of similar tracking applications for complex conditions.

Background: Heart failure (HF) readmission rates at our institution were often higher than the expected levels for our institution type. Social work post-discharge telephone calls were identified as an opportunity to address reasons for HF therapy noncompliance, a major reason for readmissions identified among HF patients at our institution.

Methods: Our study aimed to improve existing post-discharge telephone outreach performed by social workers to reduce 30-day all-cause readmission rates in traditional Medicare patients with HF at a single academic tertiary care hospital. A multidisciplinary team of social workers, nurses, and physicians created 2 HF-specific forms based on an online resource (Target: HF telephone form) provided by the American Heart Association. The first form focused on HF transition of care-related issues, while the second form focused on HF patient education. These HF-specific forms replaced a generic checklist used by social workers during their post-discharge outreach.

Results: Fifty-one patients were included in the intervention. The mean age was 76.82 years old. Most patients were male (56.9%), White (82.4%), Hispanic (58.8%), and spoke English as their preferred language (54.9%). Pre-intervention, the 30-day all-cause readmission rate ranged from 7.1% to 30.8%. Post-intervention, the 30-day all-cause readmission rate ranged from 8.3% to 25.0%. The pre-intervention mean 30-day all-cause readmission rate was 15.5% with a standard deviation of 8.1%, whereas the post-intervention mean was 16.8% and a standard deviation of 5.3% (P = .721).

Conclusions: HF-specific structured telephone support by social workers post-discharge did not reduce 30-day all-cause readmission rates in an elderly, traditional Medicare population with HF.

Background and objectives: With the potential to lead to liver failure, cirrhosis, and death and the availability of hepatitis C Virus (HCV) treatment with direct-acting antiviral medications, primary care clinicians need to take action to improve screening and treatment of HCV. Current literature demonstrates gaps in knowledge contribute to low HCV screening and treatment rates. The project's purpose is to use a multidisciplinary approach to patient and clinician education to improve HCV care in a rural primary care clinic.

Methods: This quality improvement project involved 1225 adult patients aged 18-79 seen at a rural Federally Qualified Health Center (FQHC) in Arkansas, from February 15 to April 1, 2024. The project applied the Chronic Care Model to promote change in decision support and clinical information systems by educating patients and clinicians, reinforcing care accuracy, and monitoring practice. Project interventions included provider, clinical staff, and patient education and improving the visibility of the patient's HCV screening status in the electronic medical record (EMR). The clinic manager and marketing director assisted the project leader with educational training. The laboratory director designated an area for HCV screening history in the EMR, and the quality director evaluated the program's efficacy. A manual retrospective chart review was performed to evaluate the program's effectiveness. The collected data were analyzed using descriptive statistics to demonstrate the efficacy of the quality improvement project.

Results: Following the implementation of this project, providers at the clinic demonstrated an improved understanding of current HCV screening and treatment guidelines. Additionally, the HCV screening rates for eligible adults increased from the baseline screening rate of 42% to 44.8% with 549 of 1225 eligible patients screened for HCV during the project implementation period. Additionally, 100% (n = 4) of adult patients diagnosed with HCV from February 15, 2024, to April 1, 2024, initiated HCV treatment ordered by their primary care provider.

Conclusions: While the short duration of the project poses a limitation, implications from this project to current practice point to the importance of innovative changes in information technologies as well as patient, staff, and clinician education to improve access to HCV screening and care in rural primary care clinics. Further, to improve the quality of care and the screening and treatment of HCV, rural health clinics and organizations should consider updating policies and procedures to standardize HCV screening for adults aged 18-79.

Background and objectives: This paper defines quality improvement (QI), describes the differences and connections among QI, clinical audit/quality assurance, and clinical research, highlights the importance of strong organizational governance for QI, and provides a simplified, evidence-based QI methodology that can be readily used by health care staff.

Methods: The authors draw on their diverse QI experiences, encompassing a university maternity hospital, a radiation oncology specialist center, an acute general hospital, senior health care management, and academia. This demonstrates the feasibility of implementing QI in diverse health care settings and by all members of the multidisciplinary team.

Results: Embedding QI in clinical audit, incident, and service user feedback management enables learning from Quality and Patient Safety activities, driving evidence-based improvements by frontline staff. Strong governance and accountability are essential to ensure QI efforts are sustained and impactful. QI also supports and enhances clinical research activities, improving patient outcomes and care.

Conclusion: QI is most effective when it is kept simple, includes frontline multidisciplinary teams and patients/service users, and is supported by staff with QI expertise. This paper demonstrates the successful application of a QI methodology across varied health care specialties, emphasizing its broad applicability and significant benefits for health care delivery.

Background and objectives: Venous thromboembolism (VTE) prophylaxis remains important in managing hospitalized patients. Many studies have been done to incorporate educational interventions and other measures to help achieve better rates of appropriate VTE prophylaxis usage. Our objective was to study the sole impact of resident education, focusing on reducing heparin usage compared to low molecular weight heparin.

Methods: This study was carried out in a single upstate New York hospital. Preintervention data were collected regarding VTE prophylaxis usage among the resident team for 5 weeks followed by a month of educational intervention where residents were given PowerPoint presentations and handouts during our educational conferences. Postintervention data were then collected for a 5-week period and subsequently analyzed.

Results: The preintervention arm had 579 patients, while the postintervention arm had 311 patients. Our results did not show a statistically significant decrease in inappropriate heparin use after the intervention (20.8% vs 17.5%, P value = .326). A higher nonstatistically significant percentage of patients were shifted from Heparin to Enoxaparin on resolution of acute kidney injury in the postintervention group (73.9% vs 55.2%, P value = .077). There was no difference in adverse events of heparin induced thrombocytopenia, bleeding, and deep venous thrombosis/pulmonary embolism between the groups.

Conclusions: Our study suggests that education alone cannot significantly change appropriate VTE usage rates. Other means of increasing appropriate VTE usage or a combination of education with other means need to be explored further.

Background and objectives: A sensation becomes a symptom (a concern) when a person associates it with potential illness. In the absence of objective evidence of a pathophysiological process that has important health consequences without treatment, assigning a diagnosis to the sensation is optional. This is important because labeling of benign bodily sensations as pathophysiology has potential advantages and disadvantages. We asked what patient and clinician factors are associated with willingness to accept an optional diagnosis.

Methods: In a survey administered using Amazon M-Turk, 536 people anonymously completed validated measures for symptoms of anxiety and depression, intolerance of uncertainty, and skepticism regarding the healthcare system. They then viewed fictional personal medical scenarios in which they were asked to imagine they experienced certain symptoms, and were offered an optional diagnosis of a nerve problem, muscle pain syndrome, or fatigue syndrome, and were asked to rate their willingness to accept the diagnosis on an 12-point ordinal scale from 0 indicating "I do not accept it at all" to 11 indicating "I accept it with enthusiasm." The language of the scenarios was varied to attempt to reflect critical thinking, denigration of other doctors, an alternative mental health focus, or a hopeful outlook. Multilevel linear regression was used to identify factors associated with likelihood of accepting an optional diagnosis.

Results: Threshold likelihood of accepting an optional diagnosis greater than 5.5 on a 0 to 11 ordinal scale was independently associated with greater symptoms of anxiety (regression coefficient [RC] = 0.38, 95% confidence interval [95% CI] = 0.30-0.47, P < .001), greater skepticism regarding the healthcare system (RC = 0.11, 95% CI = 0.076-0.13, P < .001), and delivery tones characterized by either denigration of other doctors (RC = 0.39, 95% CI = 0.19-0.60, P < .001) or a hopeful outlook (RC = 0.50, 95% CI = 0.26-0.73, P < .001).

Conclusion: Likelihood of accepting an optional diagnosis may be a sign of relative vulnerability from feelings of distress or distrust of medical evidence. Given this potential vulnerability, clinicians can take care to limit persuasive communication styles that can influence acceptance of optional diagnoses.

Background and objectives: Unplanned hospital readmissions (UHRs) constitute a persistent health concern worldwide. A high level of UHRs imposes a burden on individuals, their families, and health care system budgets. This systematic review and meta-analysis aimed to evaluate the effectiveness of discharge interventions in the transition from hospital to home in the context of reducing UHRs.

Methods: The study design was a meta-analysis of randomized and nonrandomized controlled trials. Eight databases were searched. The effect on UHR rates (odds ratio [OR]) of discharge interventions in the transition from hospital to home was calculated at a 95% confidence interval (95% CI) based on meta-regression and meta-analysis of random-effects models.

Results: Results showed that discharge interventions were effective in reducing rehospitalizations (effectiveness/OR =1.39; 95% CI, 1.24-1.55). It was furthermore determined that the studies showed heterogeneous characteristics ( P ≤ .001, Q = 50.083, I2 = 44.093; df = 28). According to Duval and Tweedie's trim and fill results, there was no publication bias. Interventions in which telephone communications and hospital visits (OR = 1.64; 95% CI, 1.25-2.16; P < .001) were applied together were effective among patients with cardiovascular diseases (OR = 1.54; 95% CI, 1.28-2.09; P < .001), and it was found that UHRs were reduced within a period of 90 days (OR = 1.68; 95% CI, 1.16-2.42; P < .001). It was also found that discharge interventions applied to transitions from hospital to home had a diminishing effect on UHRs as the publication dates of the reviewed studies advanced from the past to the present (OR = 0.015; 95% CI, 0.002-0.003; P < .001).

Conclusion: Supporting and facilitating cooperation between health care professionals and families should be a key focus of discharge interventions.

Background and objective: Value-based payment programs link payments to the performance of providers on cost and quality of care to incentivize high-value care. To improve quality and lower costs, the Centers for Medicare and Medicaid Services (CMS) implemented the Quality Payment Program (QPP) for clinicians in 2017. Under the Medicare QPP, most eligible clinicians participate in one of the payment models: (a) Advanced Alternative Payment Models (A-APMs) through eligible APMs like Accountable Care Organizations (ACOs) or (b) the Merit-based Incentive Payment System (MIPS). ACO and MIPS clinicians participating in QPP differ in quality reporting requirements, and these differences are likely to affect the utilization of different quality measures, including preventive services. This study evaluated the differences in the utilization of preventive services by primary care clinicians participating in MIPS and ACOs.

Methods: We use difference-in-difference regressions to compare preventive services in MIPS versus ACOs. Since preventive services like immunization and certain cancer screening are mandatory reporting measures for ACOs and voluntary measures for MIPS, the treatment group for this study is ACO clinicians and the comparison group is non-ACO MIPS clinicians. We obtained the rates of influenza immunization, pneumonia vaccination, tobacco use cessation intervention, depression screening, colorectal cancer screening, breast cancer screening, and wellness visits per 10 000 Medicare beneficiaries from Medicare Provider Utilization and Payment Public Use File (2012-2018).

Results: We had 508 144 total observations (ACO = 25.78% and MIPS = 74.22%) from 72 592 unique primary care clinicians. Compared to MIPS clinicians, ACO clinicians had significantly higher rates of pneumonia vaccination (incidence rate ratio [IRR] 1.25; 95% confidence interval [CI], 1.10-1.43) but lower rates of colorectal cancer screening (IRR 0.69; 95% CI, 0.50-0.96). Similarly, clinicians in ACO shared savings-only models had significantly higher rates of pneumonia vaccination (IRR 1.28; 95% CI, 1.11-1.48), depression screening (IRR 1.72; 95% CI, 1.09-2.71), and wellness visits (IRR 1.27; 95% CI, 1.09-1.47) compared to MIPS clinicians. There were no differences between ACO and MIPS clinicians on the utilization of breast cancer screening procedures and tobacco use cessation interventions.

Conclusions: ACO clinicians may have prioritized relatively low-cost services such as pneumonia vaccination, depression screening, and wellness visits to improve their performance under QPP. Policymakers may need to alter incentives in performance-based payment programs to ensure that clinicians are improving all types of quality measures, including cancer screening.