Patient involvement in rheumatoid arthritis care to improve disease activity-based management in daily practice: A randomized controlled trial.

OBJECTIVE: To evaluate the effect of an intervention to improve disease activity-based management of RA in daily clinical practice by addressing patient level barriers. METHODS: The DAS-pass strategy aims to increase patients' knowledge about DAS28 and to empower patients to be involved in treatment (decisions). It consists of an informational leaflet, a patient held record and guidance by a specialized rheumatology nurse. In a Randomized Controlled Trial, 199 RA patients were randomized 1:1 to intervention or control group. Outcome measures were patient empowerment (EC-17; primary outcome), attitudes towards medication (BMQ), disease activity (DAS28) and knowledge about DAS28. RESULTS: Our strategy did not affect EC-17, BMQ, or DAS28 use. However it demonstrated a significant improvement of knowledge about DAS28 in the intervention group, compared to the control group. The intervention had an additional effect on patients with low baseline knowledge compared to patients with high baseline knowledge. CONCLUSION: The DAS-pass strategy educates patients about (the importance of) disease activity-based management, especially patients with low baseline knowledge. PRACTICE IMPLICATIONS: The strategy supports patient involvement in disease activity-based management of RA and can be helpful to reduce inequalities between patients in the ability to be involved in shared decision making.

Proxy indicators to estimate appropriateness of antibiotic prescriptions by general practitioners: a proof-of-concept cross-sectional study based on reimbursement data, north-eastern France 2017.

BackgroundIn most countries, including France, data on clinical indications for outpatient antibiotic prescriptions are not available, making it impossible to assess appropriateness of antibiotic use at prescription level.AimOur objectives were to: (i) propose proxy indicators (PIs) to estimate appropriateness of antibiotic use at general practitioner (GP) level based on routine reimbursement data; and (ii) assess PIs' performance scores and their clinimetric properties using a large regional reimbursement database.MethodsA recent systematic literature review on quality indicators was the starting point for defining a set of PIs, taking French national guidelines into account. We performed a cross-sectional study analysing National Health Insurance data (available at prescriber and patient levels) on antibiotics prescribed by GPs in 2017 for individuals living in north-eastern France. We measured performance scores of the PIs and their case-mix stability, and tested their measurability, applicability, and room for improvement (clinimetric properties).ResultsThe 3,087 GPs included in this study prescribed a total of 2,077,249 antibiotic treatments. We defined 10 PIs with specific numerators, denominators and targets. Performance was low for almost all indicators ranging from 9% to 75%, with values < 30% for eight of 10 indicators. For all PIs, we found large variation between GPs and patient populations (case-mix stability). Regarding clinimetric properties, all PIs were measurable, applicable, and showed high improvement potential.ConclusionsThe set of 10 PIs showed satisfactory clinimetric properties and might be used to estimate appropriateness of antibiotic prescribing in primary care, in an automated way within antibiotic stewardship programmes.

Perioperative diabetes care: development and validation of quality indicators throughout the entire hospital care pathway.

BACKGROUND: In this study, we aim to develop a set of quality indicators for optimal perioperative diabetes care throughout the hospital care pathway and to gain insight into the feasibility of the indicator set in daily clinical practice by assessing the clinimetric properties of the indicators in a practice test. METHODS: A literature-based modified Delphi method was used to develop a set of quality indicators. To assess clinimetric properties of each indicator (measurability, applicability, reliability, improvement potential and case-mix stability), a practice test was performed in six Dutch hospitals using a sample of 389 major surgery patients with diabetes who underwent abdominal, cardiac or large joint orthopaedic surgery. RESULTS: We developed a set of 36 quality indicators for perioperative diabetes care. The practice test showed that one indicator was inapplicable, and nine indicators were unmeasurable. Interobserver reliability was good (0.61≤k≤0.8) for all indicators except for one with moderate (0.41≤k≤0.6) interobserver reliability. Improvement potential was low (<10%) for five indicators. Twenty-one indicators, including three outcome indicators, nine process indicators and nine structure indicators, could be used to assess the quality of care delivered in our six study hospitals. CONCLUSION: We developed a face and content valid set of quality indicators for optimal perioperative diabetes care throughout the hospital care pathway, using a rigorous and systematic approach. The results from our practice test show that it is essential to subject indicators to a practice test before applying them for quality improvement purposes. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT01610674.

Short- and long-term effects of a quality improvement collaborative on diabetes management.

INTRODUCTION: This study examined the short- and long-term effects of a quality improvement collaborative on patient outcomes, professional performance, and structural aspects of chronic care management of type 2 diabetes in an integrated care setting. METHODS: Controlled pre- and post-intervention study assessing patient outcomes (hemoglobin A1c, cholesterol, blood pressure, weight, blood lipid levels, and smoking status), professional performance (guideline adherence), and structural aspects of chronic care management from baseline up to 24 months. Analyses were based on 1,861 patients with diabetes in six intervention and nine control regions representing 37 general practices and 13 outpatient clinics. RESULTS: Modest but significant improvement was seen in mean systolic blood pressure (decrease by 4.0 mm Hg versus 1.6 mm Hg) and mean high density lipoprotein levels (increase by 0.12 versus 0.03 points) at two-year follow up. Positive but insignificant differences were found in hemoglobin A1c (0.3%), cholesterol, and blood lipid levels. The intervention group showed significant improvement in the percentage of patients receiving advice and instruction to examine feet, and smaller reductions in the percentage of patients receiving instruction to monitor blood glucose and visiting a dietician annually. Structural aspects of self-management and decision support also improved significantly. CONCLUSIONS: At a time of heightened national attention toward diabetes care, our results demonstrate a modest benefit of participation in a multi-institutional quality improvement collaborative focusing on integrated, patient-centered care. The effects persisted for at least 12 months after the intervention was completed. TRIAL NUMBER: http://clinicaltrials.gov Identifier: NCT 00160017.

Factors influencing success in quality-improvement collaboratives: development and psychometric testing of an instrument.

BACKGROUND: To increase the effectiveness of quality-improvement collaboratives (QICs), it is important to explore factors that potentially influence their outcomes. For this purpose, we have developed and tested the psychometric properties of an instrument that aims to identify the features that may enhance the quality and impact of collaborative quality-improvement approaches. The instrument can be used as a measurement instrument to retrospectively collect information about perceived determinants of success. In addition, it can be prospectively applied as a checklist to guide initiators, facilitators, and participants of QICs, with information about how to perform or participate in a collaborative with theoretically optimal chances of success. Such information can be used to improve collaboratives. METHODS: We developed an instrument with content validity based on literature and the opinions of QIC experts. We collected data from 144 healthcare professionals in 44 multidisciplinary improvement teams participating in two QICs and used exploratory factor analysis to assess the construct validity. We used Cronbach's alpha to ascertain the internal consistency. RESULTS: The 50-item instrument we developed reflected expert-opinion-based determinants of success in a QIC. We deleted nine items after item reduction. On the basis of the factor analysis results, one item was dropped, which resulted in a 40-item questionnaire. Exploratory factor analysis showed that a three-factor model provided the best fit. The components were labeled 'sufficient expert team support', 'effective multidisciplinary teamwork', and 'helpful collaborative processes'. Internal consistency reliability was excellent (alphas between .85 and .89). CONCLUSIONS: This newly developed instrument seems a promising tool for providing healthcare workers and policy makers with useful information about determinants of success in QICs. The psychometric properties of the instrument are satisfactory and warrant application either as an objective measure or as a checklist.