Journal for Healthcare Quality最新文献

Introduction: Prosthetic joint infection (PJI) after total hip and knee arthroplasty (TJA) is a major cause of morbidity in orthopedics. Fully specified quality measures for PJI diagnosis are lacking. We aimed to specify and evaluate electronic clinical quality measures (eCQM) across different healthcare institutions.

Methods: Measures were specified using an iterative process through which elements in the measures were identified and evaluated, and their capture optimized in the electronic health record (EHR). Measures were then retrospectively tested at three institutions. Performance on the measures at each institution, and across surgeons at one, was also assessed. Qualitative interviews with each institution identified technical, structural, and clinical reasons for poor performance on the measures.

Results: Four of the five eCQMs could be implemented within the EHRs. Wide variations were found in measure performance. Qualitative interviews revealed differences in EHR coding, data not being shared within institutions, and focus on specific tests within the testing set as reasons for poor performance.

Conclusions: Significant variability in posthetic joint infection eCQMs exists, driven both by variations in data availability and clinical practice. Electronic clinical quality measures hold significant potential to enhance diagnostic quality measurement, but successful implementation is highly dependent on process standardization, data accuracy, and adaptation of measures across healthcare settings.

Abstract: Patient throughput issues are of significant concern for U.S. hospitals and have serious implications for patient care quality and safety as well as hospital finances. In 2021, leaders of a community hospital commissioned a quality improvement team to address a bottleneck of patients in the emergency department (ED). The bottleneck was causing significant increases in the number of hours patients were held in the ED because of a lack of available inpatient beds. The team used the DMAIC improvement framework to analyze patient flow challenges across the hospital, design an evidence-based set of interventions, and measure improvements. Analysis revealed problems with communication breakdowns and workflow silos, discharge predictability, readiness of patients for discharge, timeliness of discharges, and lack of standardization in patient hand-offs and documentation processes. Addressing these issues resulted in patient throughput improvements including a reduction of greater than 75% in monthly ED hold hours after implementation.

Introduction: Risk of stroke is greater in patients with atrial fibrillation. Anticoagulation is effective at decreasing risk, yet 40-50% of eligible patients are not prescribed anticoagulation and seem to have a concerning gap in care quality. This quality improvement initiative implemented a pharmacist-led approach to identify, verify, and close apparent anticoagulation treatment gaps.

Methods: We included adult primary care patients with diagnosis of atrial fibrillation; congestive heart failure, hypertension, age ≥75 years (doubled), diabetes, stroke/transient ischemic attack (doubled), vascular disease, age 65-74 years, and sex (female) (CHA 2 DS 2 -VASc) score of at least 2, and no current anticoagulant use. We identified patients using claims and electronic health record data and evaluated explanations through chart review and provider contact. A provider outreach protocol was developed and implemented to address opportunities for anticoagulation.

Results: Of 242 patients with an apparent gap, 84% had a verified treatment gap. However, 86% of verified treatment gaps were explained through pharmacist chart review and outreach to providers, and they did not require further action. Explanations included spontaneous resolution of atrial fibrillation, patient declining treatment, completion of a procedure to correct atrial fibrillation or mitigate stroke risk, and high bleeding risk.

Conclusions: Relying solely on claims- and electronic health record-based algorithms may substantially overestimate gaps in care quality.

Abstract: Since 2011, hospitals in the United States have used the Total Harm Rate as a metric to address and enhance patient safety by mitigating harmful events. However, upon evaluation, it was concluded that this tool had lost its validity and was not widely used as an effective measure to prevent harm to patients. There are no similar comparative data in the literature to which we can compare our results with others. The Quality Management Performance Improvement team began to develop a composite safety score that would be used to reflect the environment of patient safety and promote improvement opportunities.

Introduction: Careful preoperative patient preparation for orthopedic foot and ankle surgery can help manage postoperative expectations and avoid suboptimal outcomes. Our quality improvement initiative aimed to reduce emergency department (ED) visits within 30 days postsurgery by enhancing preoperative education.

Methods: We focused on four outcomes associated with receipt of written preoperative information: (1) related ED visits within 30 days of surgery, (2) average number of patient portal messages, (3) phone calls initiated by patients, and (4) staff team experience survey results. All patients undergoing foot and ankle surgery by two surgeons at one institution from July 2023 to January 2024 were included.

Results: Through a series of six plan, do, study, act (PDSA) cycles lasting 1 month each, we evaluated 431 patients (55.9% female, 61.4% White, 92.4% English speakers). Patients who received written preoperative information were significantly less likely to present to the ED for related concerns within 30 days of surgery compared with those receiving no written preoperative information ( p = .0068). In addition, we observed fewer portal messages and phone calls from patients receiving written preoperative information ( p = .3644, p = .0541).

Conclusions: An increase in the use of standardized written preoperative information yields decreased ED visits and frequency of inquiries from patients through portal messages and phone calls.

Introduction: With growing recognition of the influence that social risks, such as food insecurity and housing instability, have on individual and population health, social risk screening and social care interventions have proliferated across the health system. Social needs intervention research on screening and referral in specialty care is limited, despite evidence that social needs influence access to and outcomes of surgical and specialty care.

Methods: This study is a qualitative, formative evaluation of a quality improvement-oriented social needs screening and referral pilot program implemented in a bariatric surgery practice and aims to share lessons related to the structure and process components of a quality improvement (QI) framework.

Results: Semistructured interviews revealed variation in patient eligibility for resources and highlighted the need for enhanced staff capacity and data system integration. In addition, process-related themes including patient hesitation toward referrals, variability in screening pathways, and uncertainty surrounding communication practices emerged in qualitative analyses.

Conclusions: Implementation of social needs screening and referral programs in specialty care setting is feasible but requires unique structure and process-related considerations. Incorporating QI infrastructure into these programs allows for continuous evaluation of program processes and can be used to evaluate the impact of these programs on health outcomes.

Background: Evidence-based guidelines recommend statins as first-line therapy to reduce the risk of cardiovascular events in patients with cardiovascular disease and/or diabetes. The Centers for Medicare and Medicaid Services assess compliance with these guidelines through performance and process quality measures.

Purpose: To describe innovative practices to address statin use care gaps, to identify successes and challenges of a pharmacist-led statin initiative, and share quality improvement opportunities related to statin quality metrics.

Methods: A retrospective review was conducted in 2023 of patients enrolled in Medicare Advantage value-based care contracts in a large health system. The primary outcome measures were the percentage of patients identified with statin care gaps who met the criteria for statin treatment and the percentage of patients who accepted pharmacist-led recommendations to initiate statin therapy. Outcomes were analyzed using descriptive statistics.

Results: Among those with statin care gaps, 42% met criteria for pharmacist-led statin initiation. Of those who met criteria, 22% accepted pharmacist's recommendation to initiate statin therapy.

Conclusions: Pharmacist-led statin initiation is effective; however, systematic barriers remain to improve statin quality performance. These results can help others adopt innovative practices that target statin care gaps and assess opportunities for quality improvement.

Objective: This study develops a hospital quality index to analyze state-level variations in hospital quality in the United States from 2013 to 2021, using data from 3,000 hospitals from the Centers for Medicare & Medicaid Services (CMS) Hospital Compare data set.

Design: The quality index combines three risk-adjusted measures from the CMS Hospital Compare: 30-day readmission rate, 30-day mortality rate, and patient experience. Each measure is converted into a z-score, weighted by hospital beds, and averaged to form the final index, which has a mean of 0 and a standard deviation of 1.

Results: In 2021, the average U.S. hospital quality measures were 15.1% for readmissions, 11.2% for mortality, and 69.7% for patient experience. There was significant state-level heterogeneity. The quality index ranged from -0.54 to 0.57. Eight states notably outperformed the U.S. average, with Utah leading. Conversely, 14 states underperformed. From 2013 to 2021, there was an average annual improvement in readmissions (0.08pp) and mortality (0.12pp), but a decline in patient experience (0.27pp).

Conclusions: The study highlights improvements in hospital quality over time but underscores disparities at the state level. The quality index provides a valuable tool for understanding and addressing these variations in hospital care quality.

Background: Alcohol withdrawal syndrome (AWS) is highly prevalent in hospital inpatients. Recent evidence supports use of phenobarbital and gabapentin in certain patients, and screening tools for severe withdrawal risk can be used to guide care. Inpatients with AWS should also be considered for evidence-based treatment for alcohol use disorder (AUD).

Purpose: The purpose of this quality improvement study was to monitor clinical outcomes and prescribing habits after updating an electronic order set for inpatient AWS management at a large, academic hospital.

Methods: Protocol updates included use of the Prediction of Alcohol Withdrawal Severity Scale, phenobarbital and gabapentin protocols, and linkage to treatment resources. Data were collected for 10 months before and 14 months after implementation.

Results: Intensive care unit (ICU) transfer rate decreased by 2.3%, whereas length of stay and readmissions were not significantly different. In patients treated with the order set, ICU transfer and length of stay outcomes were superior. Patients treated through the order set were more likely to receive evidence-based treatment for AWS and AUD.

Conclusions: Electronic order sets can promote evidence-based practice for AWS. The updated protocol will remain in place at the study institution, with future efforts focused on education and ease of use to increase order set utilization.

Abstract: Despite the importance of early detection of diabetic retinopathy, many diabetic patients fail to receive the recommended screening. The objective of this quality-improvement initiative was to increase diabetic retinopathy screening through a partnership between primary care and ophthalmology, where primary care clinic staff may schedule patients directly for screening appointments at point of referral. To our knowledge, this intervention is the first described to use an interspecialty partnership to increase screening. We implemented the intervention at a resident-run primary care clinic with a medically underserved patient population. The pilot intervention took place over a 6-month time frame. The completion rate of diabetic retinopathy screening examinations was compared before and after intervention and was found to increase in a statistically significant manner from 34.7% to 40.5% ( p = .01). The no-show rate did improve from 66.7% preintervention to 46.0% postintervention; however, this change was not statistically significant ( p = .44). During this pilot, the intervention was able to increase diabetic retinopathy screening completion rate; however, further efforts should be aimed at addressing no-shows. Overall, this initiative was a positive step toward the goal of every diabetic patient undergoing the appropriate screening examinations.