Pub Date : 2019-08-23DOI: 10.1136/bmjqs-2019-010062
Christopher R. Manz, K. Rendle, J. Bekelman
In USA, cancer outcomes have steadily improved but considerable disparities in outcomes persist.1 There is continued evidence that vulnerable patients (ie, those who are socially or economically disadvantaged) are less likely to receive high-quality care and subsequently have poorer outcomes.2 Since the release of the Institute of Medicine’s report Ensuring Quality Cancer Care in 1999, increased attention has been paid to the importance of measuring cancer care quality, understanding its effects on outcomes and identifying effective strategies for ensuring that all patients have access to high-quality cancer care.3 Studies have demonstrated that patient survival varies by hospital type (eg, community vs academic cancer centre), even after risk adjustment for tumour characteristics and comorbidities, and that patients treated at hospitals that perform worse on some cancer quality metrics have inferior survival.4–10 Collectively, these findings suggest that variations in cancer care quality translate into decreased survival for thousands of patients every year, and vulnerable patients are at particular risk of poorer cancer outcomes. The intended goals of quality metrics are to allow hospitals to identify and improve on substandard care, thereby elevating individual and population level cancer care quality, while also enabling patients and payers to choose high-performing hospitals through public reporting. There has been close consideration of how best to measure quality that addresses social drivers of poor cancer outcomes, without punishing hospitals that treat large numbers of vulnerable patients. While quality metrics that focus on the outcomes that matter most to cancer patients—living longer (overall survival) and living better (quality of life)—would be preferred, this is very difficult in practice as these outcomes may indirectly hold hospitals accountable for extrinsic socioeconomic factors beyond their direct control.11 12 The limitations attached to using survival and quality of life outcomes as quality metrics mean that the substantial …
{"title":"Mind the gap: how vulnerable patients fall through the cracks of cancer quality metrics","authors":"Christopher R. Manz, K. Rendle, J. Bekelman","doi":"10.1136/bmjqs-2019-010062","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-010062","url":null,"abstract":"In USA, cancer outcomes have steadily improved but considerable disparities in outcomes persist.1 There is continued evidence that vulnerable patients (ie, those who are socially or economically disadvantaged) are less likely to receive high-quality care and subsequently have poorer outcomes.2 Since the release of the Institute of Medicine’s report Ensuring Quality Cancer Care in 1999, increased attention has been paid to the importance of measuring cancer care quality, understanding its effects on outcomes and identifying effective strategies for ensuring that all patients have access to high-quality cancer care.3 Studies have demonstrated that patient survival varies by hospital type (eg, community vs academic cancer centre), even after risk adjustment for tumour characteristics and comorbidities, and that patients treated at hospitals that perform worse on some cancer quality metrics have inferior survival.4–10 Collectively, these findings suggest that variations in cancer care quality translate into decreased survival for thousands of patients every year, and vulnerable patients are at particular risk of poorer cancer outcomes.\u0000\u0000The intended goals of quality metrics are to allow hospitals to identify and improve on substandard care, thereby elevating individual and population level cancer care quality, while also enabling patients and payers to choose high-performing hospitals through public reporting. There has been close consideration of how best to measure quality that addresses social drivers of poor cancer outcomes, without punishing hospitals that treat large numbers of vulnerable patients. While quality metrics that focus on the outcomes that matter most to cancer patients—living longer (overall survival) and living better (quality of life)—would be preferred, this is very difficult in practice as these outcomes may indirectly hold hospitals accountable for extrinsic socioeconomic factors beyond their direct control.11 12 \u0000\u0000The limitations attached to using survival and quality of life outcomes as quality metrics mean that the substantial …","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"91 - 94"},"PeriodicalIF":0.0,"publicationDate":"2019-08-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-010062","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48723201","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-22DOI: 10.1136/bmjqs-2018-008852
D. McIsaac, G. Hamilton, K. Abdulla, L. Lavallée, H. Moloo, C. Pysyk, J. Tufts, W. Ghali, A. Forster
Objective Administrative data systems are used to identify hospital-based patient safety events; few studies evaluate their accuracy. We assessed the accuracy of a new set of patient safety indicators (PSIs; designed to identify in hospital complications). Study design Prospectively defined analysis of registry data (1 April 2010–29 February 2016) in a Canadian hospital network. Assignment of complications was by two methods independently. The National Surgical Quality Improvement Programme (NSQIP) database was the clinical reference standard (primary outcome=any in-hospital NSQIP complication); PSI clusters were assigned using International Classification of Disease (ICD-10) codes in the discharge abstract. Our primary analysis assessed the accuracy of any PSI condition compared with any complication in the NSQIP; secondary analysis evaluated accuracy of complication-specific PSIs. Patients All inpatient surgical cases captured in NSQIP data. Analysis We assessed the accuracy of PSIs (with NSQIP as reference standard) using positive and negative predictive values (PPV/NPV), as well as positive and negative likelihood ratios (±LR). Results We identified 12 898 linked episodes of care. Complications were identified by PSIs and NSQIP in 2415 (18.7%) and 2885 (22.4%) episodes, respectively. The presence of any PSI code had a PPV of 0.55 (95% CI 0.53 to 0.57) and NPV of 0.93 (95% CI 0.92 to 0.93); +LR 6.41 (95% CI 6.01 to 6.84) and −LR 0.40 (95% CI 0.37 to 0.42). Subgroup analyses (by surgery type and urgency) showed similar performance. Complication-specific PSIs had high NPVs (95% CI 0.92 to 0.99), but low to moderate PPVs (0.13–0.61). Conclusion Validation of the ICD-10 PSI system suggests applicability as a first screening step, integrated with data from other sources, to produce an adverse event detection pathway that informs learning healthcare systems. However, accuracy was insufficient to directly identify or rule out individual-level complications.
目的:利用管理数据系统识别基于医院的患者安全事件;很少有研究评估它们的准确性。我们评估了一套新的患者安全指标(psi)的准确性;设计用于识别院内并发症)。研究设计对加拿大医院网络中的注册数据(2010年4月1日至2016年2月29日)进行前瞻性定义分析。并发症分别由两种方法指定。国家手术质量改进计划(NSQIP)数据库为临床参考标准(主要结局=任何院内NSQIP并发症);在出院摘要中使用国际疾病分类(ICD-10)代码分配PSI集群。我们的初步分析评估了任何PSI情况与NSQIP中任何并发症的准确性;二次分析评估了并发症特异性psi的准确性。NSQIP数据中捕获的所有住院手术病例。我们采用阳性和阴性预测值(PPV/NPV)以及阳性和阴性似然比(±LR)来评估psi(以NSQIP为参考标准)的准确性。结果:我们确定了12898例相关的护理事件。PSIs和NSQIP分别在2415次(18.7%)和2885次(22.4%)发作中发现并发症。任何PSI编码的存在PPV为0.55 (95% CI 0.53 ~ 0.57)， NPV为0.93 (95% CI 0.92 ~ 0.93);+LR 6.41 (95% CI 6.01至6.84)和- LR 0.40 (95% CI 0.37至0.42)。亚组分析(按手术类型和紧急程度)显示相似的结果。并发症特异性psi具有高npv (95% CI 0.92 ~ 0.99)，但低至中等ppv(0.13 ~ 0.61)。ICD-10 PSI系统的验证表明，与其他来源的数据相结合，可作为第一步筛选步骤，以产生不良事件检测途径，为学习医疗保健系统提供信息。然而，准确性不足以直接识别或排除个人层面的并发症。
{"title":"Validation of new ICD-10-based patient safety indicators for identification of in-hospital complications in surgical patients: a study of diagnostic accuracy","authors":"D. McIsaac, G. Hamilton, K. Abdulla, L. Lavallée, H. Moloo, C. Pysyk, J. Tufts, W. Ghali, A. Forster","doi":"10.1136/bmjqs-2018-008852","DOIUrl":"https://doi.org/10.1136/bmjqs-2018-008852","url":null,"abstract":"Objective Administrative data systems are used to identify hospital-based patient safety events; few studies evaluate their accuracy. We assessed the accuracy of a new set of patient safety indicators (PSIs; designed to identify in hospital complications). Study design Prospectively defined analysis of registry data (1 April 2010–29 February 2016) in a Canadian hospital network. Assignment of complications was by two methods independently. The National Surgical Quality Improvement Programme (NSQIP) database was the clinical reference standard (primary outcome=any in-hospital NSQIP complication); PSI clusters were assigned using International Classification of Disease (ICD-10) codes in the discharge abstract. Our primary analysis assessed the accuracy of any PSI condition compared with any complication in the NSQIP; secondary analysis evaluated accuracy of complication-specific PSIs. Patients All inpatient surgical cases captured in NSQIP data. Analysis We assessed the accuracy of PSIs (with NSQIP as reference standard) using positive and negative predictive values (PPV/NPV), as well as positive and negative likelihood ratios (±LR). Results We identified 12 898 linked episodes of care. Complications were identified by PSIs and NSQIP in 2415 (18.7%) and 2885 (22.4%) episodes, respectively. The presence of any PSI code had a PPV of 0.55 (95% CI 0.53 to 0.57) and NPV of 0.93 (95% CI 0.92 to 0.93); +LR 6.41 (95% CI 6.01 to 6.84) and −LR 0.40 (95% CI 0.37 to 0.42). Subgroup analyses (by surgery type and urgency) showed similar performance. Complication-specific PSIs had high NPVs (95% CI 0.92 to 0.99), but low to moderate PPVs (0.13–0.61). Conclusion Validation of the ICD-10 PSI system suggests applicability as a first screening step, integrated with data from other sources, to produce an adverse event detection pathway that informs learning healthcare systems. However, accuracy was insufficient to directly identify or rule out individual-level complications.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"209 - 216"},"PeriodicalIF":0.0,"publicationDate":"2019-08-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2018-008852","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48225582","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-19DOI: 10.1136/bmjqs-2018-009039
Karen Busk Nørøxe, A. Pedersen, A. H. Carlsen, F. Bro, P. Vedsted
Background Physicians’ work conditions and mental well-being may affect healthcare quality and efficacy. Yet the effects on objective measures of healthcare performance remain understudied. This study examined mental well-being, job satisfaction and self-rated workability in general practitioners (GPs) in relation to hospitalisations for ambulatory care sensitive conditions (ACSC-Hs), a register-based quality indicator affected by referral threshold and prevention efforts in primary care. Methods This is an observational study combining data from national registers and a nationwide questionnaire survey among Danish GPs. To ensure precise linkage of each patient with a specific GP, partnership practices were not included. Study cases were 461 376 adult patients listed with 392 GPs. Associations between hospitalisations in the 6-month study period and selected well-being indicators were estimated at the individual patient level and adjusted for GP gender and seniority, list size, and patient factors (comorbidity, sociodemographic characteristics). Results The median number of ACSC-Hs per 1000 listed patients was 10.2 (interquartile interval: 7.0–13.7). All well-being indicators were inversely associated with ACSC-Hs, except for perceived stress (not associated). The adjusted incidence rate ratio was 1.26 (95% CI 1.13 to 1.42) for patients listed with GPs in the least favourable category of self-rated workability, and 1.19 (95% CI 1.05 to 1.35), 1.15 (95% CI 1.04 to 1.27) and 1.14 (95% CI 1.03 to 1.27) for patients listed with GPs in the least favourable categories of burn-out, job satisfaction and general well-being (the most favourable categories used as reference). Hospitalisations for conditions not classified as ambulatory care sensitive were not equally associated. Conclusions ACSC-H frequency increased with decreasing levels of GP mental well-being, job satisfaction and self-rated workability. These findings imply that GPs’ work conditions and mental well-being may have important implications for individual patients and for healthcare expenditures.
背景医生的工作条件和心理健康状况可能影响医疗保健的质量和效果。然而，对医疗绩效客观指标的影响仍未得到充分研究。本研究调查了心理健康，工作满意度和自评工作能力在全科医生(全科医生)有关住院门诊护理敏感条件(ACSC-Hs)，注册为基础的质量指标，受转诊阈值和初级保健预防工作的影响。方法:本研究是一项观察性研究，结合了丹麦全科医生的全国登记和问卷调查数据。为了确保每个患者与特定全科医生的精确联系，合作实践不包括在内。研究病例为461 376例成人患者，392名全科医生。在6个月的研究期间，住院治疗与选定的幸福指标之间的关系在个体患者水平上进行了估计，并根据全科医生的性别和资历、名单大小和患者因素(合并症、社会人口特征)进行了调整。结果每1000例患者中位ACSC-Hs数为10.2例(四分位数间隔为7.0 ~ 13.7)。除感知压力外，所有幸福感指标均与ACSC-Hs呈负相关(不相关)。在自评工作能力最差类别的全科医生中，调整后的发病率比为1.26 (95% CI 1.13至1.42)，在倦怠、工作满意度和总体幸福感(作为参考的最有利类别)最差类别的全科医生中，调整后的发病率比为1.19 (95% CI 1.05至1.35)、1.15 (95% CI 1.04至1.27)和1.14 (95% CI 1.03至1.27)。不属于门诊敏感的住院情况的相关程度并不相等。结论ACSC-H频率随全科医生心理幸福感、工作满意度和自评工作性水平的降低而升高。这些发现暗示全科医生的工作条件和心理健康可能对个体患者和医疗保健支出有重要影响。
{"title":"Mental well-being, job satisfaction and self-rated workability in general practitioners and hospitalisations for ambulatory care sensitive conditions among listed patients: a cohort study combining survey data on GPs and register data on patients","authors":"Karen Busk Nørøxe, A. Pedersen, A. H. Carlsen, F. Bro, P. Vedsted","doi":"10.1136/bmjqs-2018-009039","DOIUrl":"https://doi.org/10.1136/bmjqs-2018-009039","url":null,"abstract":"Background Physicians’ work conditions and mental well-being may affect healthcare quality and efficacy. Yet the effects on objective measures of healthcare performance remain understudied. This study examined mental well-being, job satisfaction and self-rated workability in general practitioners (GPs) in relation to hospitalisations for ambulatory care sensitive conditions (ACSC-Hs), a register-based quality indicator affected by referral threshold and prevention efforts in primary care. Methods This is an observational study combining data from national registers and a nationwide questionnaire survey among Danish GPs. To ensure precise linkage of each patient with a specific GP, partnership practices were not included. Study cases were 461 376 adult patients listed with 392 GPs. Associations between hospitalisations in the 6-month study period and selected well-being indicators were estimated at the individual patient level and adjusted for GP gender and seniority, list size, and patient factors (comorbidity, sociodemographic characteristics). Results The median number of ACSC-Hs per 1000 listed patients was 10.2 (interquartile interval: 7.0–13.7). All well-being indicators were inversely associated with ACSC-Hs, except for perceived stress (not associated). The adjusted incidence rate ratio was 1.26 (95% CI 1.13 to 1.42) for patients listed with GPs in the least favourable category of self-rated workability, and 1.19 (95% CI 1.05 to 1.35), 1.15 (95% CI 1.04 to 1.27) and 1.14 (95% CI 1.03 to 1.27) for patients listed with GPs in the least favourable categories of burn-out, job satisfaction and general well-being (the most favourable categories used as reference). Hospitalisations for conditions not classified as ambulatory care sensitive were not equally associated. Conclusions ACSC-H frequency increased with decreasing levels of GP mental well-being, job satisfaction and self-rated workability. These findings imply that GPs’ work conditions and mental well-being may have important implications for individual patients and for healthcare expenditures.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"28 1","pages":"1006 - 997"},"PeriodicalIF":0.0,"publicationDate":"2019-08-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2018-009039","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42069388","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-10DOI: 10.1136/bmjqs-2019-009836
Elaine C. Khoong, Alicia Fernández
Preventable hospital readmissions are considered a marker of care quality. Readmissions burden patients and their families and are a significant driver of healthcare costs.1 2 In the USA (where we are based), readmission penalties have resulted in an array of interventions, ranging from the relatively simple (eg, ensuring a timely follow-up appointment) to bundled interventions with multiple components (eg, medication reconciliation plus phone follow-up plus structured handoff to outpatient clinicians).3 Evaluation results, however, have been mixed and progress in reducing readmissions difficult. Studies generally have provided limited details about interventions and the patient groups involved, making it impossible to know what worked for whom.3 4 Complicating the practical implications of this research is that bundled interventions, which tend to be more successful, require greater investment of clinical and financial resources and at times result in net financial loss, significantly dampening health system enthusiasm for implementation of programmes to reduce admissions.5 Importantly, despite well-documented racial/ethnic disparities in readmission rates,6 many studies in the USA have taken a ‘one-size-fits-all’ approach by designing interventions that do not attempt to address the specific needs or circumstances of diverse populations. The study by lead author and colleagues in this issue of BMJ Quality & Safety 7 differs from much of the readmission literature in two important ways. First, the study focused on discharge practices and activities adapted for diverse populations. Working with a patient population in Israel that included a diverse groups of patients—Russian-speaking immigrants from the former Soviet Union, Arabic-speakers from several ethnic groups and Hebrew-speakers—the authors examined the association of what they termed cultural factors (eg, …
{"title":"Language, culture and preventable readmissions: pragmatic, intervention studies needed","authors":"Elaine C. Khoong, Alicia Fernández","doi":"10.1136/bmjqs-2019-009836","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009836","url":null,"abstract":"Preventable hospital readmissions are considered a marker of care quality. Readmissions burden patients and their families and are a significant driver of healthcare costs.1 2 In the USA (where we are based), readmission penalties have resulted in an array of interventions, ranging from the relatively simple (eg, ensuring a timely follow-up appointment) to bundled interventions with multiple components (eg, medication reconciliation plus phone follow-up plus structured handoff to outpatient clinicians).3 Evaluation results, however, have been mixed and progress in reducing readmissions difficult. Studies generally have provided limited details about interventions and the patient groups involved, making it impossible to know what worked for whom.3 4 Complicating the practical implications of this research is that bundled interventions, which tend to be more successful, require greater investment of clinical and financial resources and at times result in net financial loss, significantly dampening health system enthusiasm for implementation of programmes to reduce admissions.5 Importantly, despite well-documented racial/ethnic disparities in readmission rates,6 many studies in the USA have taken a ‘one-size-fits-all’ approach by designing interventions that do not attempt to address the specific needs or circumstances of diverse populations.\u0000\u0000The study by lead author and colleagues in this issue of BMJ Quality & Safety 7 differs from much of the readmission literature in two important ways. First, the study focused on discharge practices and activities adapted for diverse populations. Working with a patient population in Israel that included a diverse groups of patients—Russian-speaking immigrants from the former Soviet Union, Arabic-speakers from several ethnic groups and Hebrew-speakers—the authors examined the association of what they termed cultural factors (eg, …","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"28 1","pages":"859 - 861"},"PeriodicalIF":0.0,"publicationDate":"2019-08-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009836","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48293872","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-08DOI: 10.1136/bmjqs-2019-009545
L. Lapointe‐Shaw, C. Bell, P. Austin, L. Abrahamyan, N. Ivers, Ping Li, P. Pechlivanoglou, D. Redelmeier, L. Dolovich
Background In-hospital medication review has been linked to improved outcomes after discharge, yet there is little evidence to support the use of community pharmacy-based interventions as part of transitional care. Objective To determine whether receipt of a postdischarge community pharmacy-based medication reconciliation and adherence review is associated with a reduced risk of death or re-admission. Design Propensity score-matched cohort study. Setting Ontario, Canada Participants Patients over age 66 years discharged home from an acute care hospital from 1 April 2007 to 16 September 2016. Exposure MedsCheck, a publicly funded medication reconciliation and adherence review provided by community pharmacists. Main outcome The primary outcome was time to death or re-admission (defined as an emergency department visit or urgent rehospitalisation) up to 30 days. Secondary outcomes were the 30-day count of outpatient physician visits and time to adverse drug event. Results MedsCheck recipients had a lower risk of 30-day death or re-admission (23.4% vs 23.9%, HR 0.97, 95% CI 0.95 to 1.00, p=0.02), driven by a decreased risk of death (1.7% vs 2.1%, HR 0.79, 95% CI 0.73 to 0.86) and rehospitalisation (11.0% vs 11.4%, HR 0.96, 95% 0.93–0.99). In a post hoc sensitivity analysis with pharmacy random effects added to the propensity score model, these results were substantially attenuated. There was no significant difference in 30-day return to the emergency department (22.5% vs 22.8%, HR 0.99, 95% CI 0.96 to 1.01) or adverse drug events (1.5% vs 1.5%, HR 1.03, 95% CI 0.94 to 1.12). MedsCheck recipients had more outpatient visits (mean 2.11 vs 2.09, RR 1.01, 95% CI 1.00 to 1.02, p=0.02). Conclusions and relevance Among older adults, receipt of a community pharmacy-based medication reconciliation and adherence review was associated with a small reduced risk of short-term death or re-admission. Due to the possibility of unmeasured confounding, experimental studies are needed to clarify the relationship between postdischarge community pharmacy-based medication review and patient outcomes.
背景:住院药物审查与出院后预后的改善有关，但很少有证据支持将社区药房干预作为过渡护理的一部分。目的确定出院后接受社区药房药物调节和依从性审查是否与降低死亡或再入院风险相关。设计倾向评分匹配队列研究。加拿大安大略省，参与者2007年4月1日至2016年9月16日从一家急症护理医院出院的66岁以上患者。曝光MedsCheck，由社区药剂师提供的公共资助的药物调节和依从性审查。主要结局:主要结局为死亡或再入院时间(定义为急诊科就诊或紧急再住院)长达30天。次要结果是30天门诊医生就诊次数和药物不良事件发生时间。结果MedsCheck受者30天死亡或再入院的风险较低(23.4% vs 23.9%， HR 0.97, 95% CI 0.95 ~ 1.00, p=0.02)，这是由于死亡风险降低(1.7% vs 2.1%， HR 0.79, 95% CI 0.73 ~ 0.86)和再入院风险降低(11.0% vs 11.4%， HR 0.96, 95% 0.93 ~ 0.99)。在倾向评分模型中加入药物随机效应的事后敏感性分析中，这些结果被大大削弱了。30天内急诊科复诊率(22.5% vs 22.8%， HR 0.99, 95% CI 0.96 ~ 1.01)或药物不良事件(1.5% vs 1.5%， HR 1.03, 95% CI 0.94 ~ 1.12)无显著差异。MedsCheck接受者有更多的门诊就诊(平均2.11 vs 2.09, RR 1.01, 95% CI 1.00 ~ 1.02, p=0.02)。在老年人中，接受以社区药房为基础的药物调节和依从性评估与短期死亡或再入院风险的小幅降低有关。由于可能存在无法测量的混杂因素，需要进行实验研究来阐明出院后社区药房药物评价与患者预后之间的关系。
{"title":"Community pharmacy medication review, death and re-admission after hospital discharge: a propensity score-matched cohort study","authors":"L. Lapointe‐Shaw, C. Bell, P. Austin, L. Abrahamyan, N. Ivers, Ping Li, P. Pechlivanoglou, D. Redelmeier, L. Dolovich","doi":"10.1136/bmjqs-2019-009545","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009545","url":null,"abstract":"Background In-hospital medication review has been linked to improved outcomes after discharge, yet there is little evidence to support the use of community pharmacy-based interventions as part of transitional care. Objective To determine whether receipt of a postdischarge community pharmacy-based medication reconciliation and adherence review is associated with a reduced risk of death or re-admission. Design Propensity score-matched cohort study. Setting Ontario, Canada Participants Patients over age 66 years discharged home from an acute care hospital from 1 April 2007 to 16 September 2016. Exposure MedsCheck, a publicly funded medication reconciliation and adherence review provided by community pharmacists. Main outcome The primary outcome was time to death or re-admission (defined as an emergency department visit or urgent rehospitalisation) up to 30 days. Secondary outcomes were the 30-day count of outpatient physician visits and time to adverse drug event. Results MedsCheck recipients had a lower risk of 30-day death or re-admission (23.4% vs 23.9%, HR 0.97, 95% CI 0.95 to 1.00, p=0.02), driven by a decreased risk of death (1.7% vs 2.1%, HR 0.79, 95% CI 0.73 to 0.86) and rehospitalisation (11.0% vs 11.4%, HR 0.96, 95% 0.93–0.99). In a post hoc sensitivity analysis with pharmacy random effects added to the propensity score model, these results were substantially attenuated. There was no significant difference in 30-day return to the emergency department (22.5% vs 22.8%, HR 0.99, 95% CI 0.96 to 1.01) or adverse drug events (1.5% vs 1.5%, HR 1.03, 95% CI 0.94 to 1.12). MedsCheck recipients had more outpatient visits (mean 2.11 vs 2.09, RR 1.01, 95% CI 1.00 to 1.02, p=0.02). Conclusions and relevance Among older adults, receipt of a community pharmacy-based medication reconciliation and adherence review was associated with a small reduced risk of short-term death or re-admission. Due to the possibility of unmeasured confounding, experimental studies are needed to clarify the relationship between postdischarge community pharmacy-based medication review and patient outcomes.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"41 - 51"},"PeriodicalIF":0.0,"publicationDate":"2019-08-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009545","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48398416","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-07DOI: 10.1136/bmjqs-2018-009219
J. Needleman, Jianfang Liu, Jinjing Shang, E. Larson, P. Stone
Background The association of nursing staffing with patient outcomes has primarily been studied by comparing high to low staffed hospitals, raising concern other factors may account for observed differences. We examine the association of inpatient mortality with patients’ cumulative exposure to shifts with low registered nurse (RN) staffing, low nursing support staffing and high patient turnover. Methods Cumulative counts of exposure to shifts with low staffing and high patient turnover were used as time-varying covariates in survival analysis of data from a three-campus US academic medical centre for 2007–2012. Staffing below 75% of annual median unit staffing for each staff category and shift type was characterised as low. High patient turnover per day was defined as admissions, discharges and transfers 1 SD above unit annual daily averages. Results Models included cumulative counts of patient exposure to shifts with low RN staffing, low nursing support staffing, both concurrently and high patient turnover. The HR for exposure to shifts with low RN staffing only was 1.027 (95% CI 1.002 to 1.053, p<0.001), low nursing support only, 1.030 (95% CI 1.017 to 1.042, p<0.001) and shifts with both low, 1.025 (95% CI 1.008 to 1.043, p=0.035). For a model examining cumulative exposure over the second to fifth days of an admission, the HR for exposure to shifts with low RN staffing only was 1.048 (95% CI 0.998 to 1.100, p=0.061), low nursing support only, 1.032 (95% CI 1.008 to 1.057, p<0.01) and for shifts with both low,1.136 (95% CI 1.089 to 1.185, p<0.001). No relationship was observed for high patient turnover and mortality. Conclusion Low RN and nursing support staffing were associated with increased mortality. The results should encourage hospital leadership to assure both adequate RN and nursing support staffing.
{"title":"Association of registered nurse and nursing support staffing with inpatient hospital mortality","authors":"J. Needleman, Jianfang Liu, Jinjing Shang, E. Larson, P. Stone","doi":"10.1136/bmjqs-2018-009219","DOIUrl":"https://doi.org/10.1136/bmjqs-2018-009219","url":null,"abstract":"Background The association of nursing staffing with patient outcomes has primarily been studied by comparing high to low staffed hospitals, raising concern other factors may account for observed differences. We examine the association of inpatient mortality with patients’ cumulative exposure to shifts with low registered nurse (RN) staffing, low nursing support staffing and high patient turnover. Methods Cumulative counts of exposure to shifts with low staffing and high patient turnover were used as time-varying covariates in survival analysis of data from a three-campus US academic medical centre for 2007–2012. Staffing below 75% of annual median unit staffing for each staff category and shift type was characterised as low. High patient turnover per day was defined as admissions, discharges and transfers 1 SD above unit annual daily averages. Results Models included cumulative counts of patient exposure to shifts with low RN staffing, low nursing support staffing, both concurrently and high patient turnover. The HR for exposure to shifts with low RN staffing only was 1.027 (95% CI 1.002 to 1.053, p<0.001), low nursing support only, 1.030 (95% CI 1.017 to 1.042, p<0.001) and shifts with both low, 1.025 (95% CI 1.008 to 1.043, p=0.035). For a model examining cumulative exposure over the second to fifth days of an admission, the HR for exposure to shifts with low RN staffing only was 1.048 (95% CI 0.998 to 1.100, p=0.061), low nursing support only, 1.032 (95% CI 1.008 to 1.057, p<0.01) and for shifts with both low,1.136 (95% CI 1.089 to 1.185, p<0.001). No relationship was observed for high patient turnover and mortality. Conclusion Low RN and nursing support staffing were associated with increased mortality. The results should encourage hospital leadership to assure both adequate RN and nursing support staffing.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"10 - 18"},"PeriodicalIF":0.0,"publicationDate":"2019-08-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2018-009219","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49448113","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-07DOI: 10.1136/bmjqs-2019-009552
Alain K Koyama, C. Maddox, Ling Li, T. Bucknall, J. Westbrook
Background Double checking medication administration in hospitals is often standard practice, particularly for high-risk drugs, yet its effectiveness in reducing medication administration errors (MAEs) and improving patient outcomes remains unclear. We conducted a systematic review of studies evaluating evidence of the effectiveness of double checking to reduce MAEs. Methods Five databases (PubMed, Embase, CINAHL, Ovid@Journals, OpenGrey) were searched for studies evaluating the use and effectiveness of double checking on reducing medication administration errors in a hospital setting. Included studies were required to report any of three outcome measures: an effect estimate such as a risk ratio or risk difference representing the association between double checking and MAEs, or between double checking and patient harm; or a rate representing adherence to the hospital’s double checking policy. Results Thirteen studies were identified, including 10 studies using an observational study design, two randomised controlled trials and one randomised trial in a simulated setting. Studies included both paediatric and adult inpatient populations and varied considerably in quality. Among three good quality studies, only one showed a significant association between double checking and a reduction in MAEs, another showed no association, and the third study reported only adherence rates. No studies investigated changes in medication-related harm associated with double checking. Reported double checking adherence rates ranged from 52% to 97% of administrations. Only three studies reported if and how independent and primed double checking were differentiated. Conclusion There is insufficient evidence that double versus single checking of medication administration is associated with lower rates of MAEs or reduced harm. Most comparative studies fail to define or investigate the level of adherence to independent double checking, further limiting conclusions regarding effectiveness in error prevention. Higher-quality studies are needed to determine if, and in what context (eg, drug type, setting), double checking produces sufficient benefits in patient safety to warrant the considerable resources required. CRD42018103436.
{"title":"Effectiveness of double checking to reduce medication administration errors: a systematic review","authors":"Alain K Koyama, C. Maddox, Ling Li, T. Bucknall, J. Westbrook","doi":"10.1136/bmjqs-2019-009552","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009552","url":null,"abstract":"Background Double checking medication administration in hospitals is often standard practice, particularly for high-risk drugs, yet its effectiveness in reducing medication administration errors (MAEs) and improving patient outcomes remains unclear. We conducted a systematic review of studies evaluating evidence of the effectiveness of double checking to reduce MAEs. Methods Five databases (PubMed, Embase, CINAHL, Ovid@Journals, OpenGrey) were searched for studies evaluating the use and effectiveness of double checking on reducing medication administration errors in a hospital setting. Included studies were required to report any of three outcome measures: an effect estimate such as a risk ratio or risk difference representing the association between double checking and MAEs, or between double checking and patient harm; or a rate representing adherence to the hospital’s double checking policy. Results Thirteen studies were identified, including 10 studies using an observational study design, two randomised controlled trials and one randomised trial in a simulated setting. Studies included both paediatric and adult inpatient populations and varied considerably in quality. Among three good quality studies, only one showed a significant association between double checking and a reduction in MAEs, another showed no association, and the third study reported only adherence rates. No studies investigated changes in medication-related harm associated with double checking. Reported double checking adherence rates ranged from 52% to 97% of administrations. Only three studies reported if and how independent and primed double checking were differentiated. Conclusion There is insufficient evidence that double versus single checking of medication administration is associated with lower rates of MAEs or reduced harm. Most comparative studies fail to define or investigate the level of adherence to independent double checking, further limiting conclusions regarding effectiveness in error prevention. Higher-quality studies are needed to determine if, and in what context (eg, drug type, setting), double checking produces sufficient benefits in patient safety to warrant the considerable resources required. CRD42018103436.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"595 - 603"},"PeriodicalIF":0.0,"publicationDate":"2019-08-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009552","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48372808","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-07DOI: 10.1136/bmjqs-2019-009420
B. Lambert, W. Galanter, King Lup Liu, Suzanne Falck, G. Schiff, Christine Rash-Foanio, K. Schmidt, Neeha Shrestha, A. Vaida, M. Gaunt
Background To assess the specificity of an algorithm designed to detect look-alike/sound-alike (LASA) medication prescribing errors in electronic health record (EHR) data. Setting Urban, academic medical centre, comprising a 495-bed hospital and outpatient clinic running on the Cerner EHR. We extracted 8 years of medication orders and diagnostic claims. We licensed a database of medication indications, refined it and merged it with the medication data. We developed an algorithm that triggered for LASA errors based on name similarity, the frequency with which a patient received a medication and whether the medication was justified by a diagnostic claim. We stratified triggers by similarity. Two clinicians reviewed a sample of charts for the presence of a true error, with disagreements resolved by a third reviewer. We computed specificity, positive predictive value (PPV) and yield. Results The algorithm analysed 488 481 orders and generated 2404 triggers (0.5% rate). Clinicians reviewed 506 cases and confirmed the presence of 61 errors, for an overall PPV of 12.1% (95% CI 10.7% to 13.5%). It was not possible to measure sensitivity or the false-negative rate. The specificity of the algorithm varied as a function of name similarity and whether the intended and dispensed drugs shared the same route of administration. Conclusion Automated detection of LASA medication errors is feasible and can reveal errors not currently detected by other means. Real-time error detection is not possible with the current system, the main barrier being the real-time availability of accurate diagnostic information. Further development should replicate this analysis in other health systems and on a larger set of medications and should decrease clinician time spent reviewing false-positive triggers by increasing specificity.
目的:评估一种用于检测电子健康记录(EHR)数据中相似/相似声音(LASA)药物处方错误的算法的特异性。设置城市，学术医疗中心，包括495个床位的医院和门诊诊所，在Cerner电子病历上运行。我们提取了8年的用药单和诊断声明。我们授权了一个药物适应症数据库，对其进行了改进，并将其与药物数据合并。我们开发了一种算法，该算法基于名称相似度、患者接受药物治疗的频率以及诊断声明是否证明药物治疗是合理的，从而触发LASA错误。我们根据相似性对触发器进行分层。两名临床医生审查了一份图表样本，以确定是否存在真正的错误，分歧由第三名审稿人解决。我们计算特异性、阳性预测值(PPV)和产率。结果该算法分析了488 481个订单，生成了2404个触发器(0.5%)。临床医生回顾了506例病例，确认存在61例错误，总体PPV为12.1% (95% CI 10.7%至13.5%)。无法测量灵敏度或假阴性率。该算法的特异性随名称相似度以及预期和分配的药物是否具有相同的给药途径而变化。结论LASA用药错误自动检测是可行的，可以发现目前其他方法无法发现的错误。目前的系统不可能实时检测错误，主要障碍是准确诊断信息的实时可用性。进一步的发展应在其他卫生系统和更多的药物上复制这一分析，并应通过增加特异性来减少临床医生审查假阳性触发因素所花费的时间。
{"title":"Automated detection of wrong-drug prescribing errors","authors":"B. Lambert, W. Galanter, King Lup Liu, Suzanne Falck, G. Schiff, Christine Rash-Foanio, K. Schmidt, Neeha Shrestha, A. Vaida, M. Gaunt","doi":"10.1136/bmjqs-2019-009420","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009420","url":null,"abstract":"Background To assess the specificity of an algorithm designed to detect look-alike/sound-alike (LASA) medication prescribing errors in electronic health record (EHR) data. Setting Urban, academic medical centre, comprising a 495-bed hospital and outpatient clinic running on the Cerner EHR. We extracted 8 years of medication orders and diagnostic claims. We licensed a database of medication indications, refined it and merged it with the medication data. We developed an algorithm that triggered for LASA errors based on name similarity, the frequency with which a patient received a medication and whether the medication was justified by a diagnostic claim. We stratified triggers by similarity. Two clinicians reviewed a sample of charts for the presence of a true error, with disagreements resolved by a third reviewer. We computed specificity, positive predictive value (PPV) and yield. Results The algorithm analysed 488 481 orders and generated 2404 triggers (0.5% rate). Clinicians reviewed 506 cases and confirmed the presence of 61 errors, for an overall PPV of 12.1% (95% CI 10.7% to 13.5%). It was not possible to measure sensitivity or the false-negative rate. The specificity of the algorithm varied as a function of name similarity and whether the intended and dispensed drugs shared the same route of administration. Conclusion Automated detection of LASA medication errors is feasible and can reveal errors not currently detected by other means. Real-time error detection is not possible with the current system, the main barrier being the real-time availability of accurate diagnostic information. Further development should replicate this analysis in other health systems and on a larger set of medications and should decrease clinician time spent reviewing false-positive triggers by increasing specificity.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"28 1","pages":"908 - 915"},"PeriodicalIF":0.0,"publicationDate":"2019-08-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009420","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43889732","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-05DOI: 10.1136/bmjqs-2019-009775
K. Schmidtke, P. Nightingale, K. Reeves, S. Gallier, I. Vlaev, S. Watson, R. Lilford
Objective To evaluate the effectiveness of reminder letters informed by social normative theory (a type of ‘nudge theory’) on uptake of seasonal influenza vaccination by front-line hospital staff. Design Individually randomised controlled trial. Setting A large acute care hospital in England. Participants Front-line staff employed by the hospital (n=7540) were randomly allocated to one of four reminder types in a factorial design. Interventions The standard letter included only general information directing the staff to take up the vaccine. A second letter highlighted a type of social norm based on peer comparisons. A third letter highlighted a type of social norm based on an appeal to authority. A fourth letter included a combination of the social norms. Main outcome measure The proportion of hospital staff vaccinated on-site. Results Vaccine coverage was 43% (812/1885) in the standard letter group, 43% (818/1885) in the descriptive norms group, 43% (814/1885) in the injunctive norms group and 43% (812/1885) in the combination group. There were no statistically significant effects of either norm or the interaction. The OR for the descriptive norms factor is 1.01 (0.89–1.15) in the absence of the injunctive norms factor and 1.00 (0.88–1.13) in its presence. The OR for the injunctive norms factor is 1.00 (0.88–1.14) in the absence of the descriptive norms factor and 0.99 (0.87–1.12) in its presence. Conclusions We find no evidence that the uptake of the seasonal influenza vaccination is affected by reminders using social norms to motivate uptake.
{"title":"Randomised controlled trial of a theory-based intervention to prompt front-line staff to take up the seasonal influenza vaccine","authors":"K. Schmidtke, P. Nightingale, K. Reeves, S. Gallier, I. Vlaev, S. Watson, R. Lilford","doi":"10.1136/bmjqs-2019-009775","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009775","url":null,"abstract":"Objective To evaluate the effectiveness of reminder letters informed by social normative theory (a type of ‘nudge theory’) on uptake of seasonal influenza vaccination by front-line hospital staff. Design Individually randomised controlled trial. Setting A large acute care hospital in England. Participants Front-line staff employed by the hospital (n=7540) were randomly allocated to one of four reminder types in a factorial design. Interventions The standard letter included only general information directing the staff to take up the vaccine. A second letter highlighted a type of social norm based on peer comparisons. A third letter highlighted a type of social norm based on an appeal to authority. A fourth letter included a combination of the social norms. Main outcome measure The proportion of hospital staff vaccinated on-site. Results Vaccine coverage was 43% (812/1885) in the standard letter group, 43% (818/1885) in the descriptive norms group, 43% (814/1885) in the injunctive norms group and 43% (812/1885) in the combination group. There were no statistically significant effects of either norm or the interaction. The OR for the descriptive norms factor is 1.01 (0.89–1.15) in the absence of the injunctive norms factor and 1.00 (0.88–1.13) in its presence. The OR for the injunctive norms factor is 1.00 (0.88–1.14) in the absence of the descriptive norms factor and 0.99 (0.87–1.12) in its presence. Conclusions We find no evidence that the uptake of the seasonal influenza vaccination is affected by reminders using social norms to motivate uptake.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"189 - 197"},"PeriodicalIF":0.0,"publicationDate":"2019-08-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009775","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46124793","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-07-31DOI: 10.1136/bmjqs-2019-009839
Xi Li, H. Krumholz
Despite the great strides that have been made during China’s recent healthcare reform to improve access to healthcare,1 substantial gaps in quality persist.2 In a study of 33 tertiary hospitals in China, Jian and colleagues reported no improvement in most process indicators on healthcare quality for acute myocardial infarction, cerebral ischaemic stroke, chronic obstructive pulmonary disease and bacterial pneumonia, from 2013 to 2018.3This study provides the most contemporary evidence of quality trends during a 5-year period after the launch of China’s healthcare reform. More importantly, it covers a broad set of treatments for four common clinical conditions that are commonly used for assessing healthcare quality.4–9 The poor performance and lack of improvement in Chinese hospitals revealed in this study aligns with prior findings. In a nationally representative study on ST-segment elevation myocardial infarction (STEMI) from 2001 to 2011, no improvement was found in in-hospital mortality outcomes, which may be a result of the continued underuse of reperfusion therapy and other recommended treatments.10 Through comparisons between urban and rural hospitals, the same study also found that despite differences in treatment and the availability of advanced facilities, outcomes for patients admitted to rural hospitals were similar to those of patients who were admitted to urban hospitals, indicating that the additional resources available at urban hospitals did not result in greater benefits to patients.11 Given the tremendous political commitment and financial investment in China’s healthcare reform during the past decade, it is critical to understand how to improve nationwide healthcare quality. An important step toward improvement is to understand the reasons underlying the current quality of care in China. Overall, performance measurements are inadequate.2 The government established a nationwide claims data system—the Hospital …
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