Impact of daylight savings time on spontaneous pregnancy loss in in vitro fertilization patients.

Transition into daylight savings time (DST) has studied negative impacts on health, but little is known regarding impact on fertility. This retrospective cohort study evaluates DST impact on pregnancy and pregnancy loss rates in 1,654 autologous in vitro fertilization cycles (2009 to 2012). Study groups were identified based on the relationship of DST to embryo transfer. Pregnancy rates were similar in Spring and Fall (41.4%, 42.2%). Pregnancy loss rates were also comparable between Spring and Fall (15.5%, 17.1%), but rates of loss were significantly higher in Spring when DST occurred after embryo transfer (24.3%). Loss was marked in patients with a history of prior spontaneous pregnancy loss (60.5%).

Elucidating Reasons for Resident Underutilization of Electronic Adverse Event Reporting.

Reasons for resident underutilization of adverse event (AE) reporting systems are unclear, particularly given frequent resident exposure to AEs and near misses (NMs). Residents at an academic medical center were surveyed about AEs/NMs, barriers to reporting, patient safety climate, and educational interventions. A total of 350 of 527 eligible residents (66%) completed the survey; 77% of respondents reported involvement in an AE/NM, though only 43% had used the reporting system. Top barriers to reporting were not knowing what or how to report. Surgeons reported more than other residents (surgery, 61%; medical, 38%; hospital-based, 15%; P < .01), yet more often felt that systems were unlikely to change after reporting (surgery, 49%; medical, 28%; hospital-based. 18%; P < .01). Residents preferred discussions with supervisors (52%) and department-led conferences (46%) to increased reporting. Efforts to increase resident reporting should address common barriers to reporting as well as department-specific differences in resident knowledge, perceptions of system effectiveness, and educational preferences.

Finding the best examples of healthcare quality improvement in Sub-Saharan Africa.

BACKGROUND: The purpose of this study was to summarise the current state of healthcare quality improvement literature focusing on sub-Saharan Africa. METHODS: Conventional methods of searching the literature were quickly found to be inadequate or inappropriate, given the different needs of practitioners in sub-Saharan Africa, and the inaccessibility of the literature. RESULTS: The group derived a core list of what were deemed exemplary quality improvement articles, based on consensus and a search into the "grey" literature of quality improvement. CONCLUSIONS: Quality improvement articles from sub-Saharan Africa are difficult to find, and suffer from a lack of centrality and organisation of literature. Efforts to address this are critical to fostering the growth of quality improvement literature in developing country settings.

Care fragmentation and emergency department use among complex patients with diabetes.

OBJECTIVE: To evaluate the association between patterns of fragmented care and emergency department (ED) use among adult patients with diabetes and chronic kidney disease. STUDY DESIGN: Observational study in an open healthcare system. METHODS: The study sample included patients with diabetes and chronic kidney disease (mean estimated glomerular filtration rate, 20-60 mL/min) and with an established primary care provider. Dispersion of care was defined by a fragmentation of care index (range, 0-1), with zero reflecting all care in 1 outpatient clinic and 1 reflecting each visit at a different clinic site. We used a negative binomial model to estimate the influence of fragmentation on ED use after adjusting for patient demographic characteristics, insurance, diabetes control, and number of comorbidities; results are reported as incidence rate ratios and associated 95% confidence intervals (CIs). The main outcome measure was the number of ED visits from 2002 to 2003. RESULTS: Of 3873 patients with diabetes having an established primary care provider, 623 (16.1%) had chronic kidney disease and comprised the final study sample. On average, patients made 19.0 (95% CI, 18.5-20.4) outpatient visits and 1.2 (95% CI, 1.1-1.4) ED visits over the 2-year period. The median fragmentation of care index was 0.48; 14.3% of subjects had a fragmentation of care index of zero. In the adjusted model, a 0.1-U increase in the fragmentation of care index was associated with a 15% increase in the number of ED visits (incidence rate ratio, 1.15; 95% CI, 1.09-1.21). CONCLUSIONS: The posited benefits of specialist referrals among patients with complex diabetes may be partially negated by care fragmentation. Better models for care coordination and stronger evidence of the marginal benefits of referrals are needed.

Access to and utilization of healthcare: the provider's role.

Access to and utilization of healthcare are distinct, yet related, concepts that serve as a focus for health policy and quality improvement. This article identifies their similarities and differences, calling on previous research and reviews to elaborate on a current understanding of factors that influence both, with a particular focus on those related to the healthcare provider. Access describes an individual's ability to position oneself to receive healthcare services. Utilization presumes access and includes the formulation of a healthcare plan during a healthcare encounter and its subsequent implementation. We present a framework that envisions access and utilization as aspects of healthcare delivery that may be affected by the context within which services are delivered, the structure of the practice that delivers them and other processes leading to outcomes experienced by the healthcare consumer. Based on current trends, we anticipate that research and policy related to access and utilization over the next 5 years will be primarily driven by a focus on quality improvement. Providers are positioned to use their collective authority to exercise influence on access and quality at the individual, institutional and policy levels.