Search

Abstract Background Previous research addressed the development of a classification scheme for quality improvement systems in European hospitals. In this study we explore associations between the 'maturity' of the hospitals' quality improvement system and clinical outcomes. Methods The maturity classification scheme was developed based on survey results from 389 hospitals in eight European countries. We matched the hospitals from the Spanish sample (113 hospitals) with those hospitals participating in a nation-wide, voluntary hospital performance initiative. We then compared sample distributions and explored associations between the 'maturity' of the hospitals' quality improvement system and a range of composite outcomes measures, such as adjusted hospital-wide mortality, -readmission, -complication and -length of stay indices. Statistical analysis includes bivariate correlations for parametrically and non-parametrically distributed data, multiple robust regression models and bootstrapping techniques to obtain confidence-intervals for the correlation and regression estimates. Results Overall, 43 hospitals were included. Compared to the original sample of 113, this sample was characterized by a higher representation of university hospitals. Maturity of the quality improvement system was similar, although the matched sample showed less variability. Analysis of associations between the quality improvement system and hospital-wide outcomes suggests significant correlations for the indicator adjusted hospital complications, borderline significance for adjusted hospital readmissions and non-significance for the adjusted hospital mortality and length of stay indicators. These results are confirmed by the bootstrap estimates of the robust regression model after adjusting for hospital characteristics. Conclusions We assessed associations between hospitals' quality improvement systems and clinical outcomes. From this data it seems that having a more developed quality improvement system is associated with lower rates of adjusted hospital complications. A number of methodological and logistic hurdles remain to link hospital quality improvement systems to outcomes. Further research should aim at identifying the latent dimensions of quality improvement systems that predict quality and safety outcomes. Such research would add pertinent knowledge regarding the implementation of organizational strategies related with quality of care outcomes.

Abstract Background The Health Department of the Regional Government of Catalonia, Spain, issued a quality plan for substance abuse centers. The objective of this paper is to evaluate the impact of a multidimensional quality improvement initiative in the field of substance abuse care and to discuss potentials and limitations for further quality improvement. Methods The study uses an uncontrolled, sector-wide pre-post design. All centers providing services for persons with substance abuse issues in the Autonomous Community of Catalonia participated in this assessment. Measures of compliance were developed based on indicators reported in the literature and by broad stakeholder involvement. We compared pre-post differences in dimension-specific and overall compliance-scores using one-way ANOVA for repeated measures and the Friedman statistic. We described the spread of the data using the inter-quartile range and the Fligner-Killen statistic. Finally, we adjusted compliance scores for location and size using linear and logistic regression models. Results We performed a baseline and follow up assessment in 22 centers for substance abuse care and observed substantial and statistically significant improvements for overall compliance (pre: 60.9%; post: 79.1%) and for compliance in the dimensions 'care pathway' (pre: 66.5%; post: 83.5%) and 'organization and management' (pre: 50.5%; post: 77.2%). We observed improvements in the dimension 'environment and infrastructure' (pre: 81.8%; post: 95.5%) and in the dimension 'relations and user rights' (pre: 66.5%; post: 72.5%); however, these were not statistically significant. The regression analysis suggests that improvements in compliance are positively influenced by being located in the Barcelona region in case of the dimension 'relations and user rights'. Conclusion The positive results of this quality improvement initiative are possibly associated with the successful involvement of stakeholders, the consciously constructed feedback reports on individual and sector-wide performance and the support of evidence-based guidance wherever possible. Further research should address how contextual issues shape the uptake and effectiveness of quality improvement actions and how such quality improvements can be sustained.

Abstract Background Hospitals in European countries apply a wide range of quality improvement strategies. Knowledge of the effectiveness of these strategies, implemented as part of an overall hospital quality improvement system, is limited. Methods/Design We propose to study the relationships among organisational quality improvement systems, patient empowerment, organisational culture, professionals' involvement with the quality of hospital care, including clinical effectiveness, patient safety and patient involvement. We will employ a cross-sectional, multi-level study design in which patient-level measurements are nested in hospital departments, which are in turn nested in hospitals in different EU countries. Mixed methods will be used for data collection, measurement and analysis. Hospital/care pathway level constructs that will be assessed include external pressure, hospital governance, quality improvement system, patient empowerment in quality improvement, organisational culture and professional involvement. These constructs will be assessed using questionnaires. Patient-level constructs include clinical effectiveness, patient safety and patient involvement, and will be assessed using audit of patient records, routine data and patient surveys. For the assessment of hospital and pathway level constructs we will collect data from randomly selected hospitals in eight countries. For a sample of hospitals in each country we will carry out additional data collection at patient-level related to four conditions (stroke, acute myocardial infarction, hip fracture and delivery). In addition, structural components of quality improvement systems will be assessed using visits by experienced external assessors. Data analysis will include descriptive statistics and graphical representations and methods for data reduction, classification techniques and psychometric analysis, before moving to bi-variate and multivariate analysis. The latter will be conducted at hospital and multilevel. In addition, we will apply sophisticated methodological elements such as the use of causal diagrams, outcome modelling, double robust estimation and detailed sensitivity analysis or multiple bias analyses to assess the impact of the various sources of bias. Discussion Products of the project will include a catalogue of instruments and tools that can be used to build departmental or hospital quality and safety programme and an appraisal scheme to assess the maturity of the quality improvement system for use by hospitals and by purchasers to contract hospitals.

Abstract Background The first step of handling health promotion (HP) in Diagnosis Related Groups (DRGs) is a systematic documentation and registration of the activities in the medical records. So far the possibility and tradition for systematic registration of clinical HP activities in the medical records and in patient administrative systems have been sparse. Therefore, the activities are mostly invisible in the registers of hospital services as well as in budgets and balances. A simple model has been described to structure the registration of the HP procedures performed by the clinical staff. The model consists of two parts; first part includes motivational counselling (7 codes) and the second part comprehends intervention, rehabilitation and after treatment (8 codes). The objective was to evaluate in an international study the usefulness, applicability and sufficiency of a simple model for the systematic registration of clinical HP procedures in day life. Methods The multi centre project was carried out in 19 departments/hospitals in 6 countries in a clinical setup. The study consisted of three parts in accordance with the objectives. A: Individual test. 20 consecutive medical records from each participating department/hospital were coded by the (coding) specialists at local department/hospital, exclusively (n = 5,529 of 5,700 possible tests in total). B: Common test. 14 standardized medical records were coded by all the specialists from 17 departments/hospitals, who returned 3,046 of 3,570 tests. C: Specialist evaluation. The specialists from the 19 departments/hospitals evaluated if the codes were useful, applicable and sufficient for the registration in their own department/hospital (239 of 285). Results A: In 97 to100% of the local patient pathways the specialists were able to evaluate if there was documentation of HP activities in the medical record to be coded. B: Inter rater reliability on the use of the codes were 93% (57 to 100%) and 71% (31 to 100%), respectively. C: The majority of the study participants found the codes to be useful (71%), applicable (92%) and sufficient (92%). Conclusion Systematic registration of HP activities is relevant in clinical day life and the suggested codes proved to be applicable for international use. HP is an essential part of the clinical pathway or the value chain. This model promises to improve the documentation and thereby facilitate analysis of records for evidence based medicine as well as cost and policy analyses.

Background: There is little evidence showing the effectiveness of integrated healthcare initiatives to improve population health. Moreover, current guidelines for evaluation have shortcomings that could lead to misleading conclusions. Our paper focuses on the evaluation of Gesundes Kinzigtal, a German best-practice integrated healthcare initiative previously evaluated in a quasi-experiment using propensity score matching. The challenge arises when realizing the design selectively excludes treated participants. Integrated initiatives like Gesundes Kinzigtal seek to improve health by introducing specific interventions in the whole spectrum of patients and care services, in what is known as a whole system approach. Because it is unknown where in the spectrum of patients are the biggest gains of integrated healthcare, the non-random exclusion of a portion of the sample can bias the evaluation in an unknown direction. Aim/Methods: By creating an evaluation design that overcomes previous challenges, our paper aims to correctly evaluate the effect of integrated healthcare over population health outcomes. We performed two quasi-experimental evaluations and compared their results and validity. One evaluation used the design outlined in previous literature, while the other used our new design based on entropy balancing. The evaluations compared patients enrolled in Gesundes Kinzigtal to a control group of non-enrolled patients of the region and follow them for 5 years. Claims data from 2004 to 2018 was used. Population health outcomes correspond to survival (Cox hazard ratio, Kaplan-Meier curve), mortality ratio, mean age at the time of death, and years of life lost or gained. Results: In the entropy balancing based evaluation, 9083 treated participants were compared to an equivalent control group, showing, respectively, a mortality ratio of 5.4% vs 7.5% (p < 0.05), mean age at the time of death of 80.1 vs 80.3 (p>0.05) and a gain of 0.2 years of life per person for the treatment group (p >0.05). The Cox hazard ratio (0.72; p<0.05) indicates a lower risk of death for the treated, in line with greater mean survival time (1784 vs 1768 days; p<0.05). The results of the propensity score matching-based evaluation were more favorable to the treatment group. However, when compared to the matched participants, unmatched treated participants in the propensity score design had significantly more physician visits, hospitalizations, number of prescriptions, Charlson comorbidity score, and other indicators related to greater healthcare needs. Conclusion: Gesundes Kinzigtal had a favorable effect on the mortality and survival risk of the enrolled population at the time of assessment. Previous evaluation designs might overestimate this effect by excluding patients with greater healthcare needs. Consequently, our results suggest that health gains resulting from the integrated healthcare approach diminish for patients with high healthcare needs. Implications for applicability/transferability: Our work presents readers with a robust evaluation design to evaluate the effectiveness of integrated healthcare systems over population health outcomes. Furthermore, it provides useful insights for the discussion regarding the relationship between patient's healthcare needs and integrated healthcare health gains. [ABSTRACT FROM AUTHOR]

Background: Optimizing prescribing practices is important due to the substantial clinical and financial costs of polypharmacy and an increasingly aging population. Prior research shows the importance of social relationships in driving prescribing behaviour. Using social network analysis, we examine the relationship between a physician practices' connectedness to peers and their prescribing performance in two German regions. Methods: We first mapped physician practice networks using links established between two practices that share 8 or more patients; we calculated network-level (density, average path length) and node-level measures (degree, betweenness, eigenvector). We defined prescribing performance as the total number of inappropriate medications prescribed or appropriate medications not prescribed (PIMs) to senior patients (over the age of 65) during the calendar year 2016. We used FORTA (Fit fOR The Aged) algorithm to classify medication appropriateness. Negative binomial regression models estimate the association between node-level measures and prescribing performance of physician practices controlling for patient comorbidity, provider specialization, percentage of seniors in practice, and region. We conducted two sensitivity analyses to test the robustness of our findings – i) limiting the network mapping to patients younger than 65; ii) limiting the network ties to practices that share more than 25 patients. Results: We mapped two patient-sharing networks including 436 and 270 physician practices involving 28,508 and 20,935 patients and consisting of 217,126 and 154,274 claims in the two regions respectively. Regression analyses showed a practice's network connectedness as represented by degree, betweenness, and eigenvector centrality, is significantly negatively associated with prescribing performance (degree—bottom vs. top quartile aRR = 0.04, 95%CI: 0.035,0.045; betweenness—bottom vs. top quartile aRR = 0.063 95%CI: 0.052,0.077; eigenvector—bottom vs. top quartile aRR = 0.039, 95%CI: 0.034,0.044). Conclusions: Our study provides evidence that physician practice prescribing performance is associated with their peer connections and position within their network. We conclude that practices occupying strategic positions at the edge of networks with advantageous access to novel information are associated with better prescribing outcomes, whereas highly connected practices embedded in insulated information environments are associated with poor prescribing performance. [ABSTRACT FROM AUTHOR]

Introduction: Transitional care and patient handover are important areas to ensure quality and safety in elderly healthcare services. Previous studies showed that healthcare professionals have little knowledge of the setting they are transferring patients to and a limited understanding of roles and functions; these constitute barriers to effective communication and shared care responsibilities across levels of care. Aim: The main objective is to implement a cross-level education-based intervention programme with healthcare professionals aimed at (1) increasing professionals' awareness and competencies about quality and safety in the transitional care of the elderly; (2) creating a discussion platform for knowledge exchange and learning across levels and units of care and (3) improving patient safety culture, in particular, in transitional care. Methods and analysis: A quasi-experimental control group study design with an intervention group and a control group; this includes a pretest, post-test and 1-year follow-up test assessment of patient safety culture. Qualitative data will be collected during the intervention programme and between the measurements. The study design will be beneficial for addressing the effects of the cross-level educational intervention programme on reports of patient safety culture and for addressing the feasibility of the intervention measures. Ethics and dissemination: The study has been approved by the Regional Committees for Medical and Health Research Ethics in Norway, Ref. No. 2011/1978. The study is based on informed written consent; informants can withdraw from the study at any point in time. The results will be disseminated at research conferences, in peer review journals and through public presentations outside the scientific community. [ABSTRACT FROM AUTHOR]

Background: Handover practices at hospital discharge are relatively under-researched, particularly as regards the specific risks and additional requirements for handovers involving vulnerable patients with limited language, cognitive and social resources. Objective: To explore handover practices at discharge and to focus on the patients' role in handovers and on the potential additional risks for vulnerable patients. Methods: We conducted qualitative interviews with patients, hospital professionals and primary care professionals in two hospitals and their associated primary care centres in Catalonia, Spain. Results: We identified handover practices at discharge that potentially put patients at risk. Patients did not feel empowered in the handover but were expected to transfer information between care providers. Professionals identified lack of medication reconciliation at discharge, loss of discharge information, and absence of plans for follow-up care in the community as quality and safety problems for discharge handovers. These occurred for all patients, but appeared to be more frequent and have a greater negative effect in patients with limited language comprehension and/or lack of family and social support systems. Conclusions: Discharge handovers are often haphazard. Healthcare professionals do not consider current handover practices safe, with patients expected to transfer information without being empowered to understand and act on it. This can lead to misinformation, omission or duplication of tests or interventions and, potentially, patient harm. Vulnerable patients may be at greater risk given their limited language, cognitive and social resources. Patient safety at discharge could benefit from strategies to enhance patient education and promote empowerment. [ABSTRACT FROM AUTHOR]

Background: Hospitals in European countries apply a wide range of quality improvement strategies. Knowledge of the effectiveness of these strategies, implemented as part of an overall hospital quality improvement system, is limited. Methods/Design: We propose to study the relationships among organisational quality improvement systems, patient empowerment, organisational culture, professionals' involvement with the quality of hospital care, including clinical effectiveness, patient safety and patient involvement. We will employ a cross-sectional, multi-level study design in which patient-level measurements are nested in hospital departments, which are in turn nested in hospitals in different EU countries. Mixed methods will be used for data collection, measurement and analysis. Hospital/care pathway level constructs that will be assessed include external pressure, hospital governance, quality improvement system, patient empowerment in quality improvement, organisational culture and professional involvement. These constructs will be assessed using questionnaires. Patient-level constructs include clinical effectiveness, patient safety and patient involvement, and will be assessed using audit of patient records, routine data and patient surveys. For the assessment of hospital and pathway level constructs we will collect data from randomly selected hospitals in eight countries. For a sample of hospitals in each country we will carry out additional data collection at patient-level related to four conditions (stroke, acute myocardial infarction, hip fracture and delivery). In addition, structural components of quality improvement systems will be assessed using visits by experienced external assessors. Data analysis will include descriptive statistics and graphical representations and methods for data reduction, classification techniques and psychometric analysis, before moving to bi-variate and multivariate analysis. The latter will be conducted at hospital and multilevel. In addition, we will apply sophisticated methodological elements such as the use of causal diagrams, outcome modelling, double robust estimation and detailed sensitivity analysis or multiple bias analyses to assess the impact of the various sources of bias. Discussion: Products of the project will include a catalogue of instruments and tools that can be used to build departmental or hospital quality and safety programme and an appraisal scheme to assess the maturity of the quality improvement system for use by hospitals and by purchasers to contract hospitals. [ABSTRACT FROM AUTHOR]

Background: The first step of handling health promotion (HP) in Diagnosis Related Groups (DRGs) is a systematic documentation and registration of the activities in the medical records. So far the possibility and tradition for systematic registration of clinical HP activities in the medical records and in patient administrative systems have been sparse. Therefore, the activities are mostly invisible in the registers of hospital services as well as in budgets and balances. A simple model has been described to structure the registration of the HP procedures performed by the clinical staff. The model consists of two parts; first part includes motivational counselling (7 codes) and the second part comprehends intervention, rehabilitation and after treatment (8 codes). The objective was to evaluate in an international study the usefulness, applicability and sufficiency of a simple model for the systematic registration of clinical HP procedures in day life. Methods: The multi centre project was carried out in 19 departments/hospitals in 6 countries in a clinical setup. The study consisted of three parts in accordance with the objectives. A: Individual test. 20 consecutive medical records from each participating department/hospital were coded by the (coding) specialists at local department/hospital, exclusively (n = 5,529 of 5,700 possible tests in total). B: Common test. 14 standardized medical records were coded by all the specialists from 17 departments/ hospitals, who returned 3,046 of 3,570 tests. C: Specialist evaluation. The specialists from the 19 departments/hospitals evaluated if the codes were useful, applicable and sufficient for the registration in their own department/hospital (239 of 285). Results: A: In 97 to 100% of the local patient pathways the specialists were able to evaluate if there was documentation of HP activities in the medical record to be coded. B: Inter rater reliability on the use of the codes were 93% (57 to 100%) and 71% (31 to 100%), respectively. C: The majority of the study participants found the codes to be useful (71%), applicable (92%) and sufficient (92%). Conclusion: Systematic registration of HP activities is relevant in clinical day life and the suggested codes proved to be applicable for international use. HP is an essential part of the clinical pathway or the value chain. This model promises to improve the documentation and thereby facilitate analysis of records for evidence based medicine as well as cost and policy analyses. [ABSTRACT FROM AUTHOR]

Introduction: Ideally, high performing health systems will try to achieve the 'Triple Aim' of improving population health, enhancing the individual care experience and doing so in a cost efficient way. In reality, developed countries all over the world face challenges to focus their health care actors on these aims. A major reason for that is the financial and organizational fragmentation of their health care sector. A possible solution is seen in the implementation of an 'integrator', who organizes a close collaboration between all actors and is rewarded for the value it generates. Policy context and objective: To stipulate the formation of 'integrators' in the US the Obama Administration has introduced Accountable Care Organizations (ACOs) in 2010. Similar initiatives are also on the way in other countries, such as the UK, the Netherlands or Germany. One of Europe's most comprehensive and most referred to ACOs is the German Gesundes Kinzigtal (GK). The objective of this contribution is to highlight the distinctive features and best-practices of this ACO model and elaborate transferability to re-orienting the model of care in other countries. Targeted population: GK uses a population-based approach. The ACO is accountable for all 33,000 people living in the region that are insured by the two cooperating insurance funds (about half of the population of the whole region. Highlights: GK has generated positive impacts on all three Triple Aim dimensions in the region so far. From 2007-2014 total savings of ~$38.2 million (USD 2014) have been achieved; in 2014 ~$7 million (USD 2014, 7.4 percent). The external scientific evaluation also found that most of the quality and patient satisfaction indicators examined show a positive effect. Distinctive success factors of the ACO model are: long-term shared savings contract for geographically-defined population with upfront investment, to finance the transition and help the new model become self-sustaining, regional health management company as "integrator" (partly owned by providers), evidence-based and locally adapted interventions to reduce progression of diseases, activation of patients, shared decision making and self-management support, co mprehensive electronic health record, and business intelligence system, and interventions beyond health care, including prevention, public health and the social arena. Transferability: The ACO model of GK is currently transferred from the rural area of Kinzigtal to a socially deprived area in the city of Hamburg. Also a transmission of the GK model to the Netherlands and the UK has started. Key elements for transferability are the implementation of regional integrators and value- and population-based payment models with upfront investment or advance payments to build a financial foundation for the incremental change necessary for these value-based approaches. Conclusions: Re-orienting the model of care towards accountability for whole regions has the potential to improve quality, efficiency and patient satisfaction at the same time. The German ACO GK provides crucial lessons how a regional health system may move towards the Triple Aim and gives hints for transferability. As the ACO approach is addressing similar underlying structural challenges in most developed countries, global learning from ACO best-practices and policies should be facilitated. [ABSTRACT FROM AUTHOR]

Summary: Self‐management interventions (SMIs) may improve disease management in adults living with obesity. We formulated evidence‐based recommendations for SMIs within the context of the COMPAR‐EU project. The multidisciplinary panel selected critical outcomes based on the COMPAR‐EU core outcome set and established decision thresholds for each outcome. Recommendations were informed by systematic reviews of effects, cost‐effectiveness, and a contextual assessment. To assess the certainty of the evidence and formulate the recommendations, we used the GRADE approach guidance. Overall, SMIs were deemed to have a small impact, but the absence of harmful effects and potential cumulative benefits indicated a favourable balance of effects, despite low certainty. SMIs showed variations in structure, intensity, and resource utilisation, but overall are likely to be cost‐effective. Adapting SMIs to local contexts would enhance equity, acceptability, and feasibility, considering patients' values, and availability of resources and teamwork. Consequently, the panel made conditional recommendations favouring SMIs over usual care. The rigorous and explicit recommendations demonstrated the effectiveness of SMIs for adults living with obesity. However, the gaps in the literature influenced the panel to make only conditional recommendations in favour of SMIs. Further research is needed to strengthen the evidence base and improve recommendations' certainty and applicability. [ABSTRACT FROM AUTHOR]

Healthcare professionals have first-hand experience with patients in clinical practice and the dynamics in the healthcare system, which can be of great value in the design, implementation, data analysis and dissemination of research study results. Primary care professionals are particularly important as they provide first contact, accessible, coordinated, comprehensive and continuous people-focused care. However, in-depth examination of the engagement of health professionals in health system research and planning activities—how professionals are engaged and how this varies across national contexts- is limited, particularly in international initiatives. There is a need to identify gaps in the planning of engagement activities to inform the design and successful implementation of future international efforts to improve the responsiveness of health systems to the changing needs of patients and professionals. The aim of this study was to explore how primary care professionals were engaged in the design and implementation plans of an international health policy study led by the Organisation for Economic Co-operation and Development (OECD). The OECD's international PaRIS survey measures and disseminates information on patient-reported outcome and experience measures (PROMs and PREMs) of people living with chronic conditions who are managed in primary care. A documentary analysis of 17 written national implementation plans (country roadmaps) was conducted between January and June 2023. Two reviewers independently performed the screening and data abstraction and resolved disagreements by discussion. We reported the intended target primary care professionals, phase of the study, channel of engagement, level of engagement, and purpose of engagement. All 17 countries aimed to engage primary care professionals in the execution plans for the international PaRIS survey. While organisations of primary care professionals, particularly of family doctors, were the most commonly targeted group, variation was found in the timing of engagement activities during the different phases of the study and in the level of engagement, ranging from co-development (half of the countries co-developed the survey together with primary care professionals) to one-off consultations with whom. International guidance facilitated the participation of primary care professionals. Continuous collaborative efforts at the international and national levels can foster a culture of engagement with primary care organisations and individual professionals and enhance meaningful engagement of primary care professionals. [ABSTRACT FROM AUTHOR]

Objective: In view of the increasing number of people with (multiple) chronic conditions, the Organisation for Economic Co-operation and Development (OECD) initiated the International Survey of People Living with Chronic Conditions (PaRIS survey), which aims to provide insight in patient-reported outcomes and experiences of chronic care provided by primary care practices to support policy development. The objective of this research note is to describe the structure of the data, collected in the PaRIS survey and how the data will be analysed in a multilevel approach for cross-country comparison. Analysis plan: The data structure of the PaRIS survey represents three levels: countries/health systems, primary care practices and patients. Multilevel analysis is used because of its accuracy in estimating country-level outcomes, its flexibility in modelling relationships, and its opportunities in connecting to relevant policy questions. Country-level outcomes will be estimated to facilitate cross-country comparison and (future) within-country comparison over time. Characteristics of patients that potentially explain variation in patient-reported outcomes and experiences can be linked to primary care practice and country/health system characteristics. This makes it possible to address policy-relevant questions relating, e.g., to the impact of chronic care management on patients with a specific chronic condition. [ABSTRACT FROM AUTHOR]