BMJ Quality & Safety最新文献

Background: Newborn units in resource-constrained low-middle-income countries (LMICs) often have high neonatal mortality rates. Programmes to improve care quality often accept understaffing that directly affects care in these settings as a norm, and the effects of improving staff numbers are not studied. To address a major evidence gap, we examined the effects on quality of care of improving nurse staffing in four intermediate-level Kenyan newborn units.

Methods: We introduced three additional nurses to each of four newborn units. We measured nursing care provision using direct bedside observations with a validated structured checklist before and 6 months after intervention. Our primary outcome, changes in nurse-delivered care, was examined using descriptive analysis and multilevel modelling to adjust for confounding. We also examined the pattern of nursing care delivery and intervention fidelity.

Results: We observed a total of 1872 hours of care, over 156 nursing shifts for 290 and 300 babies before and after our intervention, respectively, across our four neonatal units. Our intervention increased the nursing hours per patient per shift observed from 34 to 43 min associated with a 4.7% increase in our primary outcome, nurse-delivered care and an 8.4% increase in delivery of 10 tasks nurses prioritise (adjusted B-coefficient 0.047 (95% CI 0.028 to 0.066) and B-coefficient 0.084 (95% CI 0.053 to 0.115), respectively). Intervention strength was reduced by changes in existing nurses' deployment and an increase in workload.

Conclusions: In very high workload settings in LMICs where nurses can only deliver a fraction of nursing care, staffing increases improve care delivery more obviously for high-priority tasks. These findings provide much needed evidence that increasing neonatal nurse staffing in under-resourced newborn units improves care quality.

Background: Stroke remains a leading global cause of death, with treatment timeliness critically determining outcomes. Although the time-efficacy relationship in stroke care is well established, the interplay interaction between treatment delays, care quality and clinical outcomes remains poorly characterised, particularly across different healthcare settings.

Methods: This nationwide study analysed data from 2 875 119 acute ischaemic stroke (AIS) hospitalisations (2020-2024). After stratifying patients by treatment delay quartiles (Q1-Q4), we performed propensity score matching to balance 24 baseline covariates. To evaluate the detrimental effects of treatment delay on therapeutic benefits, we used logistic regression and doubly robust causal modelling across delay groups. Patients whose overall delay fell within the fourth quartile and received low-quality care were identified as the high-risk group. Multivariable logistic regression was used to identify independent risk factors.

Results: Low-quality care correlated with longer delays (overall: 1038 vs 981 min, p<0.0001). High-quality care achieved the greatest mortality reduction in Q1 (average treatment effect (ATE) 0.0036, 95% CI 0.0032 to 0.0041) compared with Q4 (ATE 0.0014, 95% CI 0.0012 to 0.0017). Thrombolysis delays had the strongest impact on mortality (Q1 ATE 0.0155, 95% CI 0.0087 to 0.0222; Q4 ATE 0.0068, 95% CI 0.0031 to 0.0106). High-risk subgroups for delayed, low-quality care included: Northwest residents (OR 1.5759, 95% CI 1.5613 to 1.5905), minor stroke (OR 1.8402, 95% CI 1.8302 to 1.8503), self-transport patients (OR 1.1392, 95% CI 1.1340 to 1.1443), and those with comorbidities (renal failure: OR 1.0948, 95% CI 1.0825 to 1.1073; asthma: OR 1.0861, 95% CI 1.0646 to 1.1080) (all p<0.0001).

Conclusions: The benefits of high-quality care in reducing mortality risk were significantly diminished by delays in hospital admission, examination and thrombolysis. The timeliness and quality of AIS care are influenced by geographic location, admission National Institutes of Health Stroke Scale scores and comorbidity profiles. The highest priority populations for delay reduction and quality improvement were patients who did not use emergency medical services and those with multiple comorbidities.

Background: We previously developed a digital quality measure (dQM) of emergency presentations (EPs) in colorectal cancer (CRC) and found it to be associated with worse outcomes. Potentially avoidable EPs were common in this cohort, but identifying them required time-intensive chart reviews. We aimed to enhance the existing dQM to automate the detection of potentially avoidable EPs.

Materials and methods: We defined potentially avoidable EPs as those preceded by a CRC red flag (iron-deficiency anaemia or haematochezia ≥60 days prior, or positive stool-based screening test ≥180 days prior). The enhanced dQM was applied to a national cohort of incident CRC cases diagnosed in the Veterans Affairs healthcare system from 2017 to 2021. We examined associations with cancer stage, treatment and mortality.

Results: The enhanced dQM had a positive predictive value of 92% (95% CI 85.5% to 95.7%) for identifying potentially avoidable EPs. Among 9096 CRC cases, 28.1% were identified as EPs. Of these, 31.6% were classified as potentially avoidable. These patients were more likely to have advanced-stage disease (adjusted OR 1.50; 95% CI 1.27 to 1.78), less likely to receive treatment (adjusted OR 0.58; 95% CI 0.48 to 0.70) and had higher mortality (adjusted HR 1.58; 95% CI 1.40 to 1.79) compared with other patients with CRC.

Conclusions: The enhanced dQM accurately identified potentially avoidable EPs, which were associated with worse outcomes. This measure is unique in its focus on cases of preventable care delays, which can help guide future efforts to improve diagnostic timeliness and reduce EPs among patients with CRC.

Objective: Relational continuity of care is associated with better patient experience and health outcomes. In England, relational continuity of primary care has been declining over a decade, coinciding with an increase in patient complaints. This study investigates the relationship between relational continuity of care and patient complaints.

Methods: Cross-sectional analysis of linked practice-level data in the English National Health Service (NHS) (2016/2017-2022/2023) obtained from NHS Digital and General Practice Patient Survey (GPPS). A negative binomial model was used to investigate the association between the proportion of patients never or almost never seeing their preferred general practitioner (GP) and new written complaints per 10 000 patients, with adjustment for patient demographics, socioeconomic status, care experiences, practice care capacity and care quality. Mediation analysis was further conducted to examine patients' lost trust and unmet clinical needs as potential mechanisms.

Results: A 10 percentage point increase in the proportion of patients reporting low continuity was associated with 1.34 more new complaints per 10 000 patients (95% CI 1.23 to 1.46). The association may be stronger after than before the pandemic, among general practices with historically better continuity, and in more deprived areas. The findings were robust in using different measures of relational continuity, adjusting for primary case demand-supply mismatches, implementing a Poisson model with practice fixed effects and excluding ethnicity from the model specification. Mediation analysis showed that neither lost trust nor unmet care needs were important mediators of the effects of low continuity.

Conclusion: Self-reported low continuity of primary care is associated with more patient complaints in England. Future research should explore potential underlying mechanisms and establish whether the same relationship exists between objectively measured relational continuity and patient complaints.

Background: Increasing age is associated with reductions in kidney function and increasing polypharmacy. Most medicines are eliminated through the kidney, meaning older patients are at risk of medication accumulation and toxicity. This scoping review synthesised: (1) the prevalence at which older patients with reduced kidney function in primary care are exposed to inappropriate prescribing; (2) its associated harms; (3) the reasons for this occurring; and (4) the interventions used to improve prescribing practices.

Methods: This scoping review searched 'Medline', 'Embase', 'PsycINFO', 'CINAHL' and 'Web of Science' for publications before October 2024. References were managed on EndNote V.X5 and thematic data analysis was undertaken on Microsoft Excel. Common themes were identified, summary statistics were calculated and insights were summarised through a narrative technique.

Results: 43 relevant studies explored the scale of inappropriate prescribing, estimating prevalences of patient exposure ranging from 0.6% to 49.1% (median 24.9%). Five studies explored the associated harm from inappropriate prescribing, but only one study assessed harm as a primary outcome. Eight studies that assessed difficulties in following prescribing guidelines in reduced kidney function suggested that a lack of awareness and trusted guidelines are fundamental problems. While 13 studies evaluated interventions for improving prescribing in reduced kidney function, only two demonstrated evidence of effectiveness and only one intervention was theoretically informed.

Conclusions: Despite significant heterogeneity in study characteristics, it is clear that the prevalence of inappropriate prescribing for older people is uncomfortably high. There is a lack of evidence linking this to associated adverse outcomes, as well as identifying the causative issues driving this behaviour and the preventative interventions that could prevent harm.

Background: Thyroid function laboratory testing is often overused. Tailored de-implementation interventions require an understanding of underlying barriers and facilitators contributing to overuse.

Methods: We performed a mixed-methods study exploring barriers and facilitators of appropriate thyroid function testing using surveys and focus groups conducted between June and October 2023 in British Columbia, Canada. Quantitative survey data were summarised using simple statistics, and open-ended survey questions were summarised using summative content analysis. Focus group transcripts were analysed using thematic analysis. Key themes were mapped onto the combined Theoretical Domains Framework and Capability, Opportunity, Motivation-Behaviour model.

Results: 230 practitioners completed the survey (1.4% response rate), and 53 practitioners attended a total of six focus groups. Three themes emerged around barriers from synthesising the results: patient expectations, practitioner knowledge gaps and health system factors. Patient expectations were linked to non-specific symptoms, recommendations from alternate care providers, increased interest in hormone testing and internet searches, leading to patient requests for more testing and/or referrals to specialists. Knowledge gaps included use of specialised tests, interpretation of free hormone results, frequency of thyroid testing and screening in asymptomatic, pregnant and postpartum patients. Health system barriers included lack of practitioner time, lack of family doctors leading more patients to seek care from alternative providers, existing order sets and ordering processes, and existing culture of ordering practices. Identified facilitators of behaviour change towards appropriate thyroid testing included educational resources for practitioners and patients, leveraging of health information systems for seamless viewing of prior test results, reflexive testing and provision of personalised practitioner feedback.

Conclusions: Interventions to reduce overutilisation of thyroid testing should include easily accessible physician educational and feedback resources, patient educational materials and changes to laboratory ordering processes and information systems. Future studies should develop and evaluate the use of these intervention elements in British Columbia.

Background: The 2017 Paediatric Research in Emergency Departments International Collaborative (PREDICT) Bronchiolitis Knowledge Translation (KT) Study, a cluster randomised trial in 26 Australasian hospitals, found targeted interventions provided over one bronchiolitis season effectively de-implemented five low-value practices (salbutamol, glucocorticoids, chest radiography, antibiotics and epinephrine) by 14.1% (adjusted risk difference, 95% CI 6.5% to 21.7%; p<0.001). A 2-year follow-up study found de-implementation was sustained. This process evaluation aimed to identify factors that influenced sustainability of de-implementation of these five low-value practices in PREDICT Bronchiolitis KT Study intervention hospitals and examine fidelity and/or adaptation of the targeted interventions over 4 years post intervention delivery (sustainment).

Methods: Semistructured qualitative interviews were conducted, over 2021 and 2022, with a purposive sample of emergency department (ED) and paediatric inpatient clinicians. Data were analysed thematically into facilitators and barriers using the Consolidated Framework for Sustainability Constructs in Healthcare (CFSCH). The Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies was used to explore fidelity and adaptation.

Results: 50 clinicians (nurses: n=26; doctors: n=24) from 12 intervention hospitals were interviewed. Eight themes were identified and mapped to three CFSCH domains: (1) organisational setting; (2) initiative design and delivery and (3) people involved. Facilitators were a culture of evidence-based practice, ongoing multimodal education, strong clinical leadership as unofficial champions and the previous effectiveness of the PREDICT Bronchiolitis KT Study interventions. Barriers were lack of paediatric trained ED staff, assumptions by senior clinicians that junior doctors can provide evidence-based bronchiolitis management, bronchiolitis not a current improvement priority and lack of bronchiolitis education sessions. Use of the targeted interventions reduced over time and, when used, was adapted locally.

Conclusion: This study provides insights into factors influencing the sustainability of de-implementation of low-value care in acute care settings. Fostering an evidence-based practice culture, supported by senior leadership and ongoing multimodal education, supports sustainability of improvements in this setting.

Trial registration number: Australian and New Zealand Clinical Trials Registry No: ACTRN12621001287820.

Background: Collaborative quality initiatives (CQIs), such as the Michigan Surgical Quality Collaborative (MSQC), have invested significant resources to improve surgical outcomes over time. This study aimed to assess whether CQI efforts translated to equitable improvements for vulnerable and non-vulnerable patients alike.

Methods: We performed a retrospective observational study of patients who underwent an operation at one of 73 MSQC hospitals between 2014 and 2023. The coprimary exposures were the Distressed Communities Index (DCI), race and payer. DCI is a community index at the zip code level ranging from prosperous to distressed based on socioeconomic variables. Outcomes included 30-day complications, emergency department (ED) visits and readmissions, estimated using a logistic regression model adjusting for patient and hospital characteristics.

Results: Among 344 135 patients, the mean age (SD) was 54.7 (17.6) years and 50.7% were female. From 2014 to 2023, 30-day complications decreased for all groups stratified by DCI, race and payer. There was a disparity in complications between public versus privately insured patients (11.4% vs 9.2%, p<0.001) that significantly narrowed by the end of the study period (7.3% vs 6.6%, p=0.01). ED visits demonstrated baseline disparities by DCI (10.5% vs 7.5%, p<0.001), payer (11.1% vs 6.7%, p<0.001) and race (11.0% vs 8.2%, p<0.001). The disparity significantly narrowed by payer only (9.5% vs 6.4%, p<0.001). Readmissions decreased for all groups stratified by DCI, race and payer, but there were no significant changes in the disparities over time.

Conclusions: Our study examining surgical outcomes for a statewide CQI found that disparities in outcomes narrowed over time. Quality collaboratives may effectively improve equity in surgical outcomes, but specific attention to persistent disparities is needed to close remaining gaps.

Background: Medical safety huddles are short, structured meetings for physicians to proactively discuss and respond to profession-specific patient safety concerns, with the goal of decreasing future adverse events. Prior observational studies found associations with improved patient safety outcomes, but no randomised controlled studies have been conducted.

Objective: The primary objective was to determine the impact of medical safety huddles on adverse events. Secondary objectives included the fidelity of huddle implementation and the impact on patient safety culture among physicians.

Design: Stepped-wedge cluster randomised trial with four sequences, and each hospital site was a cluster.

Setting: Inpatient oncology, surgery and rehabilitation programmes in four academic hospitals.

Participants: Physicians in participating programmes.

Intervention: Medical safety huddles were adapted for local context and implemented sequentially based on a computer-generated random sequence every 2 months after a 4-month control period. All sites remained in the intervention phase for at least 9 months.

Main outcome and measures: The primary outcome was the rate of adverse events, as determined through blinded chart audits of 912 randomly selected patients. The fidelity of implementation was assessed through the huddle attendance rate, number of safety issues raised in the huddles and number of actions taken in response. Patient safety culture was assessed using the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety.

Results: The adjusted rate of adverse events (per 1000 patient days) in the postintervention phase was 12% lower compared with preintervention (RR: 0.88; 95% CI: 0.80 to 0.98; p=0.016). The odds of having adverse events posthuddle implementation were 17% lower in the postintervention period compared with preintervention (OR intervention vs control: 0.83; 95% CI: 0.80 to 0.87; p<0.001). The mean huddle attendance rate at each site ranged from 30% to 85%, and the mean number of issues raised per huddle and the mean number of actions taken per huddle ranged from 1.6 to 3.1. The mean (SD) overall patient safety rating increased from 2.3 (0.53) to 2.8 (0.88), p=0.010. The mean per cent (SD) positive score for the composite measures of 'Organisational learning' increased significantly from 35% (26%) to 54% (23%), p=0.00, 'Response to error' 37% (24%) to 52% (22%), p=0.025 and 'Communication about error' 36% (28%) to 64% (42%), p=0.016 after implementation.

Conclusions and relevance: Medical safety huddles decreased adverse events and may improve patient safety culture through engaging physicians.

Trial registration number: NCT05365516.