Implementation research on measuring quality in primary care: balancing national needs with learning from the Eastern Mediterranean Region.

BACKGROUND: Universal Health Coverage (UHC) is a core element of ensuring healthy lives, marking the third Sustainable Development Goal. It requires providing quality primary health-care (PHC) services. Assessment of quality of care considering a wide variety of contexts is a challenge. This study lists practical indicators to enhance the quality of PHC. OBJECTIVES: Demonstrating quality indicators for PHC that are feasible, comprehensive and adaptable to wide array of health systems and resource settings. METHODS: We applied the research framework: Exploration, Preparation, Implementation and Sustainment. Exploration included a scoping review to identify quality indicators. Preparation included an eDelphi to refine the primary indicators' list. A panel of 27 experts reviewed the list that was later pilot tested in PHC facilities. The outcomes were presented to two further expert consultations, to refine indicators and plan for broader testing. Implementation included testing the indicators through a five-step process in 40 facilities. A regional consultation in May 2016 discussed the testing outcomes. RESULTS: Initial efforts identified 83 quality indicators at the PHC level that were then refined to a 34-indicator list covering the six domains of quality. A toolkit was also developed to test the feasibility of each indicator measurement, data availability, challenges and gaps. Pilot testing provided insight into modifying and adding some indicators. Wide variability was encountered within and in between facilities, and timely initiation of antenatal care, for example, ranged 31-90% in Oman and 11-98% in Tunisia. Indicators were highly feasible, and 29 out of 34 were measured in 75% of facilities or more. While challenges included gaps in capacity for data collection, the tool showed high adaptability to the local context and was adopted by countries in the Eastern Mediterranean Region (EMR) including Libya, Oman, Iran, Pakistan, Sudan and Palestine. Stakeholders agreed on the high relevance and applicability of the proposed indicators that have been used to inform improvement. CONCLUSION: A cross-regional set of 34 quality indicators of PHC in the EMR was developed and adopted by a diverse group of countries. The toolkit showed high feasibility in pilot testing reflecting the practicality needed to encourage local uptake and sustainability. The core quality indicators are highly adaptable to different local and regional contexts regardless of current PHC strength or available resources. Continuous evaluation and sharing lessons of implementation and use are needed to ascertain the indicators' effectiveness in driving improvements in PHC and to refine and strengthen the evidence supporting the set of indicators for wider adoption.

[Hemodialysis performance in Center East Tunisia: Compliance and adequacy of biological tests (PHCET study 2014)]. / Performance des centres d'hémodialyse au Centre Est Tunisien : conformité et adéquation des examens biologiques (Étude PHCET 2014).

BACKGROUND: Determining the performance level of hemodialysis facilities, including an evaluation of biological tests, is a prerequisite for quality assessment of these healthcare structures. OBJECTIVE: The purpose of this work was to evaluate the compliance and adequacy of biological tests performed in 2014 in Center-East Tunisia hemodialysis units. METHODS: Data were collected using an analysis grid for 15 biological indicators including 11 process items and four results items used to determine the compliance and adequacy rates respectively. RESULTS: This study included 660 hemodialysis patients (sex ratio 1.16; mean age 53.9±15.32 years). A low level of compliance was noted for several biological tests (blood glucose: 0.8%; hemoglobin 34.5%). The rate of adequacy of the biological results was insufficient, especially for anemia (32.7%) and calcium-phosphorus surveillance (41.8%). Intercenter and inter-region variability was noted, both for compliance and for adequacy of biological tests. CONCLUSION: This study demonstrated low compliance of biological tests performed for hemodialysis patients and the non-adequacy of the results obtained. It is thus urgent to institute a quality management system for biological tests performed in hemodialysis units.

Pressure injury identification, measurement, coding, and reporting: Key challenges and opportunities.

Pressure injury (PI) rates are a commonly used indicator of performance of health care facilities, both in acute and subacute settings. However, measuring PI rates in an accurate and reproducible fashion has been challenging. The consequences of poor measurement may include failure to identify poorly performing institutions or incorrect accusations of poor quality care. In this article, we describe the main challenges in identification, coding, and reporting of PIs. Issues include inconsistent identification of PIs at the time of admission, variations in the intensity of PI detection, and differing approaches to coding and the adjustment for differing risks amongst different patient population. These are compounded by differences in the epidemiological approach because rates will differ according to whether patients are surveyed cross-sectionally (eg, on a set day per month) or if the survey is undertaken at discharge. In some cases, financial incentives may also influence PI reporting. We also discuss potential strategies for improving data collection and benchmarking as an aid to reducing PI prevalence.

High health care use prior to elective surgery for osteoarthritis is associated with poor postoperative outcomes: A Canadian population-based cohort study.

BACKGROUND: The characterization and influence of preoperative health care use on quality-of-care indicators (e.g., readmissions) has received limited attention in populations with musculoskeletal disorders. The purpose of this study was to characterize preoperative health care use and examine its effect on quality-of-care indicators among patients undergoing elective surgery for osteoarthritis. METHODS: Data on health care use for 124,750 patients with elective surgery for osteoarthritis in Ontario, Canada, from April 1, 2015 to March 31, 2018 were linked across health administrative databases. Using total health care use one-year previous to surgery, patients were grouped from low to very high users. We used Poisson regression models to estimate rate ratios, while examining the relationship between preoperative health care use and quality-of-care indicators (e.g., extended length of stay, complications, and 90-day hospital readmissions). We controlled for covariates (age, sex, neighborhood income, rural/urban residence, comorbidities, and surgical anatomical site). RESULTS: We found a statistically significant trend of increasing worse outcomes by health care use gradients that persisted after controlling for patient demographics and comorbidities. Findings were consistent across surgical anatomical sites. Moreover, very high users have relatively large numbers of visits to non-musculoskeletal specialists. CONCLUSIONS: Our findings highlight that information on patients' preoperative health care use, together with other risk factors (such as comorbidities), could help decision-making when benchmarking or reimbursing hospitals caring for complex patients undergoing surgery for osteoarthritis.

Impact of a Bundle of Interventions on Quality-of-Care Indicators for Staphylococcus aureus Bacteraemia: A Single-Centre, Quasi-Experimental, Before-After Study.

Staphylococcus aureus bacteraemia (SAB) is a life-threatening bloodstream infection. Improved adherence to quality-of-care indicators (QCIs) can significantly enhance patient outcomes. This quasi-experimental study evaluated the impact of a bundle of interventions on QCI adherence in adult patients with SAB. Additionally, a molecular rapid diagnostic test (mRDT) for S. aureus and methicillin resistance was introduced during weekdays. We compared pre-intervention (January-December 2022) and post-intervention (May 2023-April 2024) data on QCI adherence and time to appropriate treatment. A total of 56 and 40 SAB episodes were included in the pre- and post-intervention periods, respectively. Full QCI adherence significantly increased from 28.6% to 67.5% in the post-intervention period (p < 0.001). The mRDT diagnosed SAB in eight cases (26.6%), but the time to achieve appropriate target therapy did not improve in the post-intervention period (54 h (IQR 30-74) vs. 72 h (IQR 51-83), p = 0.131). The thirty-day mortality rate was comparable between the two periods (17.9% vs. 12.5%, p = 0.476). This study demonstrates that a bundle of interventions can substantially improve adherence to SAB management QCIs.

Association of quality-of-care indicators with asthma outcomes: A retrospective observational study for asthma care in Singapore.

Introduction: Asthma guidelines have advocated for the use of quality-of-care indicators (QCIs) in asthma management. To improve asthma care, it is important to identify effective QCIs that are actionable. This study aimed to evaluate the effect of the presence of 3 QCIs: asthma education, Asthma Control Test (ACT) and spirometry testing on the time to severe exacerbation (TTSE). Method: Data collected from the SingHealth COPD and Asthma Data Mart (SCDM), including asthma patients managed in 9 SingHealth polyclinics and Singapore General Hospital from January 2015 to December 2020, were analysed. Patients receiving Global Initiative for Asthma (GINA) Steps 3-5 treatment, with at least 1 QCI recorded, and at least 1 severe exacerbation within 1 year before the first QCI record, were included. Data were analysed using multivariate Cox regression and quasi-Poisson regression models. Results: A total of 3849 patients in the registry fulfilled the criteria. Patients with records of asthma education or ACT assessment have a lower adjusted hazard ratio (HR) for TTSE (adjusted HR=0.88, P=0.023; adjusted HR=0.83, P<0.001). Adjusted HR associated with spirometry is higher (adjusted HR=1.22, P=0.026). No QCI was significantly associated with emergency department (ED)/inpatient visits. Only asthma education and ACT showed a decrease in the number of exacerbations for multivariate analysis (asthma education estimate: -0.181, P<0.001; ACT estimate: -0.169, P<0.001). No QCI was significant for the number of exacerbations associated with ED/inpatient visits. Conclusion: Our study suggests that the perfor-mance of asthma education and ACT was associated with increased TTSE and decreased number of exacerbations, underscoring the importance of ensuring quality care in clinical practice.

Impact of adherence to individual quality-of-care indicators on the prognosis of bloodstream infection due to Staphylococcus aureus: a prospective observational multicentre cohort.

OBJECTIVES: To analyse the adherence and impact of quality-of-care indicators (QCIs) in the management of Staphylococcus aureus bloodstream infection in a prospective and multicentre cohort. METHODS: Analysis of the prospective, multicentre international S. Aureus Collaboration cohort of S. Aureus bloodstream infection cases observed between January 2013 and April 2015. Multivariable analysis was performed to evaluate the impact of adherence to QCIs on 90-day mortality. RESULTS: A total of 1784 cases were included. Overall, 90-day mortality was 29.9% and mean follow-up period was 118 days. Adherence was 67% (n = 1180/1762) for follow-up blood cultures, 31% (n = 416/1342) for early focus control, 77.6% (n = 546/704) for performance of echocardiography, 75.5% (n = 1348/1784) for adequacy of targeted antimicrobial therapy, 88.6% (n = 851/960) for adequacy of treatment duration in non-complicated bloodstream infections and 61.2% (n = 366/598) in complicated bloodstream infections. Full bundle adherence was 18.4% (n = 328/1784). After controlling for immortal time bias and potential confounders, focus control (adjusted hazard ratio = 0.76; 95% CI, 0.59-0.99; p 0.038) and adequate targeted antimicrobial therapy (adjusted hazard ratio = 0.75; 95% CI, 0.61-0.91; p 0.004) were associated with low 90-day mortality. DISCUSSION: Adherence to QCIs in S. Aureus bloodstream infection did not reach expected rates. Apart from the benefits of application as a bundle, focus control and adequate targeted therapy were independently associated with low mortality.

Reduction of 30-day death rates from Staphylococcus aureus bacteremia by mandatory infectious diseases consultation: Comparative study interventions with and without an infectious disease specialist.

OBJECTIVES: Most Japanese hospitals need to keep to higher Staphylococcus aureus bacteremia (SAB) quality-of-care indicators (QCIs) and create strategies that can maximize the effect of these QCIs with only a small number of infectious disease specialists. This study aimed to evaluate the clinical outcomes of patients with SAB before and after the enhancement of the mandatory infectious disease consultations (IDCs). METHODS: This retrospective study was conducted at a tertiary care hospital in Japan. The primary outcome was the 30-day mortality between each period. A generalized structural equation model was employed to examine the effect of the mandatory IDC enhancement on 30-day mortality among patients with SAB. RESULTS: A total of 114 patients with SAB were analyzed. The 30-day all-cause mortality differed significantly between the two periods (17.3% vs. 4.8%, P = 0.02). Age, three-QCI point ≥ 1, and Pitt bacteremia score ≥ 3 were the significant risk factors for 30-day mortality. The intervention was also significantly associated with improved adherence to QCIs. CONCLUSION: Mandatory IDCs for SAB improved 30-day mortality and adherence to QCIs after the intervention. In Japan, improving the quality of management in patients with SAB should be an important target.

Construction of nursing quality evaluation index for hematopoietic stem cell transplantation / 中国实用护理杂志

Objective To establish the index system of nursing quality evaluation for patients with hematopoietic stem cell transplantation. Methods Based on the Donabedian structure-process-result three-dimensional quality management model, the evaluation index system of nursing quality of stem cell transplantation was constructed by combining qualitative and quantitative research of literature inquiry, case review, expert inquiry and analytic hierarchy process. Results Through the second round of expert consultation, the effective recovery rate of the expert questionnaire was 100% , the expert authority coefficient was 0.813, 0.859, and the coordination coefficient was 0.235 and 0.278 respectively (P< 01). Three primary indicators, 14 secondary indicators and 48 tertiary indicators were formed to evaluate the quality of care in stem cell transplantation. The index weight coefficient was established and the consistency test was passed. Conclusion The quality index system of hematopoietic stem cell transplantation nursing is well defined, its weight allocation is reasonable, the index is clear, and it is scientific and operational.