Pub Date : 2019-09-23DOI: 10.1136/bmjqs-2019-009570
T. Green, A. Bonner, L. Teleni, Natalie K. Bradford, L. Purtell, C. Douglas, P. Yates, M. MacAndrew, Hai Yen Dao, R. Chan
Background Experience-based codesign (EBCD) is an approach to health service design that engages patients and healthcare staff in partnership to develop and improve health services or pathways of care. The aim of this systematic review was to examine the use (structure, process and outcomes) and reporting of EBCD in health service improvement activities. Methods Electronic databases (MEDLINE, CINAHL, PsycINFO and The Cochrane Library) were searched to identify peer-reviewed articles published from database inception to August 2018. Search terms identified peer-reviewed English language qualitative, quantitative and mixed methods studies that underwent independent screening by two authors. Full texts were independently reviewed by two reviewers and data were independently extracted by one reviewer before being checked by a second reviewer. Adherence to the 10 activities embedded within the eight-stage EBCD framework was calculated for each study. Results We identified 20 studies predominantly from the UK and in acute mental health or cancer services. EBCD fidelity ranged from 40% to 100% with only three studies satisfying 100% fidelity. Conclusion EBCD is used predominantly for quality improvement, but has potential to be used for intervention design projects. There is variation in the use of EBCD, with many studies eliminating or modifying some EBCD stages. Moreover, there is no consistency in reporting. In order to evaluate the effect of modifying EBCD or levels of EBCD fidelity, the outcomes of each EBCD phase (ie, touchpoints and improvement activities) should be reported in a consistent manner. Trial registration number CRD42018105879.
{"title":"Use and reporting of experience-based codesign studies in the healthcare setting: a systematic review","authors":"T. Green, A. Bonner, L. Teleni, Natalie K. Bradford, L. Purtell, C. Douglas, P. Yates, M. MacAndrew, Hai Yen Dao, R. Chan","doi":"10.1136/bmjqs-2019-009570","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009570","url":null,"abstract":"Background Experience-based codesign (EBCD) is an approach to health service design that engages patients and healthcare staff in partnership to develop and improve health services or pathways of care. The aim of this systematic review was to examine the use (structure, process and outcomes) and reporting of EBCD in health service improvement activities. Methods Electronic databases (MEDLINE, CINAHL, PsycINFO and The Cochrane Library) were searched to identify peer-reviewed articles published from database inception to August 2018. Search terms identified peer-reviewed English language qualitative, quantitative and mixed methods studies that underwent independent screening by two authors. Full texts were independently reviewed by two reviewers and data were independently extracted by one reviewer before being checked by a second reviewer. Adherence to the 10 activities embedded within the eight-stage EBCD framework was calculated for each study. Results We identified 20 studies predominantly from the UK and in acute mental health or cancer services. EBCD fidelity ranged from 40% to 100% with only three studies satisfying 100% fidelity. Conclusion EBCD is used predominantly for quality improvement, but has potential to be used for intervention design projects. There is variation in the use of EBCD, with many studies eliminating or modifying some EBCD stages. Moreover, there is no consistency in reporting. In order to evaluate the effect of modifying EBCD or levels of EBCD fidelity, the outcomes of each EBCD phase (ie, touchpoints and improvement activities) should be reported in a consistent manner. Trial registration number CRD42018105879.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"64 - 76"},"PeriodicalIF":0.0,"publicationDate":"2019-09-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009570","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42513084","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 : 2019-09-20DOI: 10.1136/bmjqs-2019-009800
J. Mehaffey, R. Hawkins, E. Charles, F. Turrentine, B. Kaplan, S. Fogel, Charles Harris, D. Reines, J. Posadas, G. Ailawadi, J. Hanks, P. Hallowell, R. S. Jones
Background Socioeconomic status affects surgical outcomes, however these factors are not included in clinical quality improvement data and risk models. We performed a prospective registry analysis to determine if the Distressed Communities Index (DCI), a composite socioeconomic ranking by zip code, could predict risk-adjusted surgical outcomes and resource utilisation. Methods All patients undergoing surgery (n=44,451) in a regional quality improvement database (American College of Surgeons-National Surgical Quality Improvement Program ACS-NSQIP) were paired with DCI, ranging from 0–100 (low to high distress) and accounting for unemployment, education level, poverty rate, median income, business growth and housing vacancies. The top quartile of distress was compared to the remainder of the cohort and a mixed effects modeling evaluated ACS-NSQIP risk-adjusted association between DCI and the primary outcomes of surgical complications and resource utilisation. Results A total of 9369 (21.1%) patients came from severely distressed communities (DCI >75), who had higher rates of most medical comorbidities as well as transfer status (8.4% vs 4.8%, p<0.0001) resulting in higher ACS-NSQIP predicted risk of any complication (8.0% vs 7.1%, p<0.0001). Patients from severely distressed communities had increased 30-day mortality (1.8% vs 1.4%, p=0.01), postoperative complications (9.8% vs 8.5%, p<0.0001), hospital readmission (7.7 vs 6.8, p<0.0001) and resource utilisation. DCI was independently associated with postoperative complications (OR 1.07, 95% CI 1.04 to 1.10, p<0.0001) as well as resource utilisation after adjusting for ACS-NSQIP predicted risk Conclusion Increasing Distressed Communities Index is associated with increased postoperative complications and resource utilisation even after ACS-NSQIP risk adjustment. These findings demonstrate a disparity in surgical outcomes based on community level socioeconomic factors, highlighting the continued need for public health innovation and policy initiatives.
背景:社会经济地位影响手术结果，但这些因素不包括在临床质量改善数据和风险模型中。我们进行了一项前瞻性登记分析，以确定贫困社区指数(DCI)，一个由邮政编码组成的综合社会经济排名，是否可以预测风险调整后的手术结果和资源利用。方法在区域质量改进数据库(美国外科医师学会-国家外科质量改进计划ACS-NSQIP)中对所有手术患者(n=44,451)进行DCI配对，DCI评分范围为0-100(低至高窘迫)，并考虑失业、教育水平、贫困率、收入中位数、业务增长和住房空置率。将困扰的前四分之一患者与队列的其余患者进行比较，并采用混合效应模型评估ACS-NSQIP风险调整后DCI与手术并发症和资源利用的主要结局之间的关联。结果9369例(21.1%)患者来自危重社区(DCI bb0.75)，其大部分医疗合并症和转院状况的发生率较高(8.4%比4.8%，p<0.0001)，导致ACS-NSQIP预测并发症的风险较高(8.0%比7.1%，p<0.0001)。来自严重贫困社区的患者30天死亡率(1.8% vs 1.4%， p=0.01)、术后并发症(9.8% vs 8.5%， p<0.0001)、再入院率(7.7 vs 6.8, p<0.0001)和资源利用率均有所增加。调整ACS-NSQIP预测风险后，DCI与术后并发症(OR 1.07, 95% CI 1.04 ~ 1.10, p<0.0001)以及资源利用率独立相关。结论:即使在ACS-NSQIP风险调整后，贫困社区指数的增加仍与术后并发症和资源利用率的增加相关。这些发现表明，基于社区层面的社会经济因素，手术结果存在差异，突出了公共卫生创新和政策举措的持续必要性。
{"title":"Community level socioeconomic status association with surgical outcomes and resource utilisation in a regional cohort: a prospective registry analysis","authors":"J. Mehaffey, R. Hawkins, E. Charles, F. Turrentine, B. Kaplan, S. Fogel, Charles Harris, D. Reines, J. Posadas, G. Ailawadi, J. Hanks, P. Hallowell, R. S. Jones","doi":"10.1136/bmjqs-2019-009800","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009800","url":null,"abstract":"Background Socioeconomic status affects surgical outcomes, however these factors are not included in clinical quality improvement data and risk models. We performed a prospective registry analysis to determine if the Distressed Communities Index (DCI), a composite socioeconomic ranking by zip code, could predict risk-adjusted surgical outcomes and resource utilisation. Methods All patients undergoing surgery (n=44,451) in a regional quality improvement database (American College of Surgeons-National Surgical Quality Improvement Program ACS-NSQIP) were paired with DCI, ranging from 0–100 (low to high distress) and accounting for unemployment, education level, poverty rate, median income, business growth and housing vacancies. The top quartile of distress was compared to the remainder of the cohort and a mixed effects modeling evaluated ACS-NSQIP risk-adjusted association between DCI and the primary outcomes of surgical complications and resource utilisation. Results A total of 9369 (21.1%) patients came from severely distressed communities (DCI >75), who had higher rates of most medical comorbidities as well as transfer status (8.4% vs 4.8%, p<0.0001) resulting in higher ACS-NSQIP predicted risk of any complication (8.0% vs 7.1%, p<0.0001). Patients from severely distressed communities had increased 30-day mortality (1.8% vs 1.4%, p=0.01), postoperative complications (9.8% vs 8.5%, p<0.0001), hospital readmission (7.7 vs 6.8, p<0.0001) and resource utilisation. DCI was independently associated with postoperative complications (OR 1.07, 95% CI 1.04 to 1.10, p<0.0001) as well as resource utilisation after adjusting for ACS-NSQIP predicted risk Conclusion Increasing Distressed Communities Index is associated with increased postoperative complications and resource utilisation even after ACS-NSQIP risk adjustment. These findings demonstrate a disparity in surgical outcomes based on community level socioeconomic factors, highlighting the continued need for public health innovation and policy initiatives.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"232 - 237"},"PeriodicalIF":0.0,"publicationDate":"2019-09-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009800","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46450256","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 : 2019-09-18DOI: 10.1136/bmjqs-2018-009165
G. Abel, M. Elliott
When the degree of variation between healthcare organisations or geographical regions is quantified, there is often a failure to account for the role of chance, which can lead to an overestimation of the true variation. Mixed-effects models account for the role of chance and estimate the true/underlying variation between organisations or regions. In this paper, we explore how a random intercept model can be applied to rate or proportion indicators and how to interpret the estimated variance parameter.
{"title":"Identifying and quantifying variation between healthcare organisations and geographical regions: using mixed-effects models","authors":"G. Abel, M. Elliott","doi":"10.1136/bmjqs-2018-009165","DOIUrl":"https://doi.org/10.1136/bmjqs-2018-009165","url":null,"abstract":"When the degree of variation between healthcare organisations or geographical regions is quantified, there is often a failure to account for the role of chance, which can lead to an overestimation of the true variation. Mixed-effects models account for the role of chance and estimate the true/underlying variation between organisations or regions. In this paper, we explore how a random intercept model can be applied to rate or proportion indicators and how to interpret the estimated variance parameter.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"28 1","pages":"1032 - 1038"},"PeriodicalIF":0.0,"publicationDate":"2019-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2018-009165","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44350807","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 : 2019-09-16DOI: 10.1136/bmjqs-2019-009950
Tanya T. Olmos-Ochoa, D. Ganz, Jenny M. Barnard, Lauren S. Penney, Neetu Chawla
Practice transformation efforts in healthcare, like the patient-centred medical home model in primary care, have spurred the development of multiple quality improvement (QI) and implementation strategies to support effective change. Nonetheless, uncertainty about how to implement and sustain change in complex healthcare settings1 2 continues to pose significant challenges. Even when practices are receptive,3 limited QI expertise, constrained resources,4 and associated staff morale and burnout5 can impact success. Although efforts among clinicians to improve primary care by embracing a culture of QI continue,6 healthcare systems are increasingly hiring additional personnel, like practice facilitators, with key performance improvement skills to promote and support change.7 However skilled, practice facilitators cannot implement change alone. Their primary function is to enable transformation by activating the healthcare context, the innovation being implemented and the actors implementing the innovation towards successful implementation of practice improvements.8 9 Compared with other individuals participating in QI efforts (eg, quality managers), facilitators are typically appointed to their role by the organisation’s leadership, have been formally trained in QI, and have project-specific content knowledge and varying levels of facilitation experience (novice to expert).10–12 Facilitators can be internal or external to the organisation and typically support change by engaging teams in activities like task management, process monitoring, relationship building, motivation and accountability checks,13 14 during inperson or distance-based (phone or video) encounters. Successful facilitators tailor the innovation to the local context, effectively integrate into the team responsible for QI, push through resistance from recipients of the innovation and remain flexible.15 Providing this type of facilitation in a dynamic (and sometimes dysfunctional) context can be emotionally and mentally taxing, with facilitators risking the same work-related stress and emotional exhaustion (burnout) as the healthcare staff they support,16 potentially defeating the purpose of facilitation. …
{"title":"Sustaining effective quality improvement: building capacity for resilience in the practice facilitator workforce","authors":"Tanya T. Olmos-Ochoa, D. Ganz, Jenny M. Barnard, Lauren S. Penney, Neetu Chawla","doi":"10.1136/bmjqs-2019-009950","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009950","url":null,"abstract":"Practice transformation efforts in healthcare, like the patient-centred medical home model in primary care, have spurred the development of multiple quality improvement (QI) and implementation strategies to support effective change. Nonetheless, uncertainty about how to implement and sustain change in complex healthcare settings1 2 continues to pose significant challenges. Even when practices are receptive,3 limited QI expertise, constrained resources,4 and associated staff morale and burnout5 can impact success. Although efforts among clinicians to improve primary care by embracing a culture of QI continue,6 healthcare systems are increasingly hiring additional personnel, like practice facilitators, with key performance improvement skills to promote and support change.7 \u0000\u0000However skilled, practice facilitators cannot implement change alone. Their primary function is to enable transformation by activating the healthcare context, the innovation being implemented and the actors implementing the innovation towards successful implementation of practice improvements.8 9 Compared with other individuals participating in QI efforts (eg, quality managers), facilitators are typically appointed to their role by the organisation’s leadership, have been formally trained in QI, and have project-specific content knowledge and varying levels of facilitation experience (novice to expert).10–12 Facilitators can be internal or external to the organisation and typically support change by engaging teams in activities like task management, process monitoring, relationship building, motivation and accountability checks,13 14 during inperson or distance-based (phone or video) encounters. Successful facilitators tailor the innovation to the local context, effectively integrate into the team responsible for QI, push through resistance from recipients of the innovation and remain flexible.15 Providing this type of facilitation in a dynamic (and sometimes dysfunctional) context can be emotionally and mentally taxing, with facilitators risking the same work-related stress and emotional exhaustion (burnout) as the healthcare staff they support,16 potentially defeating the purpose of facilitation. …","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"28 1","pages":"1016 - 1020"},"PeriodicalIF":0.0,"publicationDate":"2019-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009950","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49154856","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 : 2019-09-13DOI: 10.1136/bmjqs-2019-009739
N. Kurek, A. Darzi
We all grow old. Even surgeons. We slow down, we weaken and our skills diminish. Although individuals differ and chronological age may not be an accurate guide to biological age, we cannot hold back the advancing years. How long should we allow surgeons to keep operating? If public safety is the priority, as it must be, should there be a mandatory retirement age, as there is for pilots in the airline industry? Or is there a fair and equitable way of assessing those nearing the end of their career to ensure their competency is maintained? The ageing surgeon poses daunting challenges. For the individuals concerned, the idea of ageing may trigger fears about loss of status, identity and livelihood. Patients may worry about the quality of their care. For healthcare systems struggling to meet growing demand, this issue raises questions about capacity. Medical regulators in Australia and Canada are implementing additional checks on doctors from the age of 70 years,1 2 but most countries have no mandatory retirement age for surgeons and those where it once existed have moved away from such a prescribed approach.3 Globally, the surgical workforce is ageing, with figures of those above 65 years ranging from as high as 25% in the USA,4 and 19% in Australia and New Zealand,5 to 9% in the UK.6 Cognitive decline is evident in older surgeons, as in ageing adults generally. The 2008 Cognitive Changes and Retirement among Senior Surgeons study found a deterioration in attention, reaction time, memory and sensory changes in vision, visual processing speed and hearing.7 A further study, however, found the decline was slower in surgeons than in age-matched controls.8 Importantly though, the assessment in that study did not encompass all surgical skills. Some studies have shown that older …
{"title":"The ageing surgeon","authors":"N. Kurek, A. Darzi","doi":"10.1136/bmjqs-2019-009739","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009739","url":null,"abstract":"We all grow old. Even surgeons. We slow down, we weaken and our skills diminish. Although individuals differ and chronological age may not be an accurate guide to biological age, we cannot hold back the advancing years.\u0000\u0000How long should we allow surgeons to keep operating? If public safety is the priority, as it must be, should there be a mandatory retirement age, as there is for pilots in the airline industry? Or is there a fair and equitable way of assessing those nearing the end of their career to ensure their competency is maintained?\u0000\u0000The ageing surgeon poses daunting challenges. For the individuals concerned, the idea of ageing may trigger fears about loss of status, identity and livelihood. Patients may worry about the quality of their care. For healthcare systems struggling to meet growing demand, this issue raises questions about capacity.\u0000\u0000Medical regulators in Australia and Canada are implementing additional checks on doctors from the age of 70 years,1 2 but most countries have no mandatory retirement age for surgeons and those where it once existed have moved away from such a prescribed approach.3 Globally, the surgical workforce is ageing, with figures of those above 65 years ranging from as high as 25% in the USA,4 and 19% in Australia and New Zealand,5 to 9% in the UK.6 Cognitive decline is evident in older surgeons, as in ageing adults generally. The 2008 Cognitive Changes and Retirement among Senior Surgeons study found a deterioration in attention, reaction time, memory and sensory changes in vision, visual processing speed and hearing.7 A further study, however, found the decline was slower in surgeons than in age-matched controls.8 Importantly though, the assessment in that study did not encompass all surgical skills.\u0000\u0000Some studies have shown that older …","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"95 - 97"},"PeriodicalIF":0.0,"publicationDate":"2019-09-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009739","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44745542","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 : 2019-09-13DOI: 10.1136/bmjqs-2019-010018
A. Sheikh
There is now widespread awareness of the very considerable burden of harm and associated costs resulting from medication errors, which, in turn, has stimulated national and international drives to reduce medication-associated harm. In parallel, there is a growing appreciation that health information technology (HIT) has the potential to reduce the risk of medication errors. There is, however, a wide gulf between HIT as a structural intervention and its translation into improvements in care processes , and a wider gulf still between the process of care and improvements in health outcomes .1 What matters to patients, and their loved ones, is of course avoidance of actual harm and it is for this reason that the WHO, in launching its Third Global Safety Challenge, called it ‘Medication Without Harm’.2 Governments across the world are investing substantial sums of money in moving care from paper-based records to electronic health record (EHR) infrastructures. A key driver for this move is the belief that this will result in substantial improvements in patient safety.3 A high frequency of medication errors and preventable adverse drug events have been documented in many studies of patient safety problems, making medication safety an obvious place to start. Yet, the analysis by Holmgren et al reported in this edition demonstrates that current EHRs would fail to prevent over one-third of potentially serious medication errors in a sample of 1527 hospitals in the USA.4 …
{"title":"Realising the potential of health information technology to enhance medication safety","authors":"A. Sheikh","doi":"10.1136/bmjqs-2019-010018","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-010018","url":null,"abstract":"There is now widespread awareness of the very considerable burden of harm and associated costs resulting from medication errors, which, in turn, has stimulated national and international drives to reduce medication-associated harm. In parallel, there is a growing appreciation that health information technology (HIT) has the potential to reduce the risk of medication errors. There is, however, a wide gulf between HIT as a structural intervention and its translation into improvements in care processes , and a wider gulf still between the process of care and improvements in health outcomes .1 What matters to patients, and their loved ones, is of course avoidance of actual harm and it is for this reason that the WHO, in launching its Third Global Safety Challenge, called it ‘Medication Without Harm’.2 \u0000\u0000Governments across the world are investing substantial sums of money in moving care from paper-based records to electronic health record (EHR) infrastructures. A key driver for this move is the belief that this will result in substantial improvements in patient safety.3 A high frequency of medication errors and preventable adverse drug events have been documented in many studies of patient safety problems, making medication safety an obvious place to start. Yet, the analysis by Holmgren et al reported in this edition demonstrates that current EHRs would fail to prevent over one-third of potentially serious medication errors in a sample of 1527 hospitals in the USA.4 …","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"7 - 9"},"PeriodicalIF":0.0,"publicationDate":"2019-09-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-010018","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47681271","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 : 2019-09-13DOI: 10.1136/bmjqs-2019-009658
Emily L Kearsley-Ho, Hsin Yun Yang, S. Karunananthan, C. Laur, J. Grimshaw, N. Ivers
Health systems invest in diabetes quality improvement (QI) programmes to reduce the gap between research evidence of optimal care and current care.1 Examples of commonly used QI strategies in diabetes include programmes to measure and report quality of care (ie, audit and feedback initiatives), implementation of clinician and patient education, and reminder systems. A recent systematic review of randomised trials of QI programmes indicates that they can successfully improve quality of diabetes care and patient outcomes.2 Changes in surrogate markers such as blood glucose control, blood pressure or cholesterol levels are used to measure QI intervention effectiveness.2 However, investments in QI strategies are only worthwhile if the programmes that effectively improve care are sustained after trial completion.3 Failure to maintain QI programmes contributes to substantial research waste, resulting in suboptimal patient care since the effective interventions are not available.4 5 Furthermore, failure to redirect resources from ineffective programmes creates opportunity cost. To date, no studies have examined the sustainability of rigorously evaluated diabetes QI programmes. The objective of this study is to explore factors associated with sustained implementation of diabetes QI programmes after cessation of their research funding. In 2018, we emailed the authors of 226 trials on diabetes QI programmes and requested them to complete an online survey about their perceived sustainability of their intervention. These trials were published between 2004 and …
{"title":"When do trials of diabetes quality improvement strategies lead to sustained change in patient care?","authors":"Emily L Kearsley-Ho, Hsin Yun Yang, S. Karunananthan, C. Laur, J. Grimshaw, N. Ivers","doi":"10.1136/bmjqs-2019-009658","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009658","url":null,"abstract":"Health systems invest in diabetes quality improvement (QI) programmes to reduce the gap between research evidence of optimal care and current care.1 Examples of commonly used QI strategies in diabetes include programmes to measure and report quality of care (ie, audit and feedback initiatives), implementation of clinician and patient education, and reminder systems. A recent systematic review of randomised trials of QI programmes indicates that they can successfully improve quality of diabetes care and patient outcomes.2 Changes in surrogate markers such as blood glucose control, blood pressure or cholesterol levels are used to measure QI intervention effectiveness.2\u0000\u0000However, investments in QI strategies are only worthwhile if the programmes that effectively improve care are sustained after trial completion.3 Failure to maintain QI programmes contributes to substantial research waste, resulting in suboptimal patient care since the effective interventions are not available.4 5 Furthermore, failure to redirect resources from ineffective programmes creates opportunity cost. To date, no studies have examined the sustainability of rigorously evaluated diabetes QI programmes. The objective of this study is to explore factors associated with sustained implementation of diabetes QI programmes after cessation of their research funding.\u0000\u0000In 2018, we emailed the authors of 226 trials on diabetes QI programmes and requested them to complete an online survey about their perceived sustainability of their intervention. These trials were published between 2004 and …","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"774 - 776"},"PeriodicalIF":0.0,"publicationDate":"2019-09-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009658","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49627631","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 : 2019-09-09DOI: 10.1136/bmjqs-2019-009732
L. Aiken, D. Sloane
Empirical evidence from many published studies indicates that better hospital professional registered nurse (RN) staffing is associated with better patient outcomes, including lower mortality and failure to rescue, shorter lengths of stay, fewer readmissions, fewer complications, higher patient satisfaction and more favourable reports from patients and nurses alike related to quality of care and patient safety.1–10 There are nonetheless lingering questions and concerns about these studies and the evidence they provide. In this issue of BMJ Quality & Safety , Needleman et al 11 allude to some potentially important ones in their introduction to their paper, including making causal inferences from cross-sectional studies, the absence of evidence on whether there is an optimal level of staffing or some level of minimally acceptable staffing below which nurses are unable to deliver high-quality and safe care, the absence of measures of work environment and its impact in many studies and whether the greater or lesser presence of nursing support staff affects patient outcomes independent of, or that acts in conjunction with, the level of RN staffing. With this study by Needleman and colleagues, BMJ Quality & Safety has now published three recent papers on the outcomes of hospital nurse staffing11–13 that are responsive in different ways to some of the lingering questions about the outcomes of nurse staffing and their implications for policies and managerial decisions about investments in nursing personnel to achieve the greatest value. The first paper in the series by RN4CAST researchers12 used unique cross-sectional data to study the outcomes of variation in nurse staffing in 243 hospitals in six European countries. The outcomes included were mortality among patients who had undergone common surgical procedures, patients’ ratings of their hospitals, nurses’ assessments of quality of care and adverse care outcomes, and nurse burnout and job dissatisfaction. …
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Pub Date : 2019-09-05DOI: 10.1136/bmjqs-2019-009830
G. Elwyn, E. Nelson, A. Hager, A. Price
If the core aim of a healthcare system is to minimise both illness and treatment burden while reducing the costs of care delivery, then we must accept, however reluctantly, that our efforts are largely failing. Life expectancy in highly developed countries is declining for the first time in decades. Long-term conditions and obesity are replacing infectious diseases as the most prominent health problems in developing nations. Meanwhile, average per capita healthcare expenditures are increasing despite efforts to restrain them. For example, in the USA, the average per capita healthcare expenditures are approaching $10 000 a year and consuming over 18% of its gross domestic product. Innovations in biomedicine, information technology and healthcare delivery systems may help address some of the challenges, but instead of containing costs these innovations tend to expand services. There are indications that interest in a concept called coproduction in healthcare is increasing. The core thesis is that by leveraging professional and end user collaboration, patients can be supported to contribute more to the management of their own conditions. This is especially true when dealing with long-term conditions, where supporting the person to learn how best to reduce the burden of both illness and treatment is an undisputed good. The goal is to cocreate value. Ostrom,1 based on her seminal work as an economist, called this coproduction . The cocreation of value already lies at the heart of most service sectors. Shopping, banking and travel all enlist the end user to coproduce value in the delivery of services. Coproduction can be even more powerful where people form alliances to share resources and generate solutions, by using what Christensen et al 2 refer to as ‘facilitated networks’. Facilitated networks offer a powerful strategy that has been adopted by many organisations to increase access, and to improve quality while …
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