A quality indicator can be biased by intra-hospital heterogeneity: the case for quality of patient record keeping in France.

BACKGROUND: Since 2008, French health institutions providing medical, surgical and obstetrical care are assessed on the basis of a set of quality indicators. The French National Authority for Health developed a survey design in which 80 records are randomly selected from each institution. The main aim was to assess the effects of internal heterogeneity of a hospital that comprises several units. The survey method is based on the hypothesis of intra-institution homogeneity, which overlooks the fact that in wide hospitals homogeneity is related to departments and thus leads to overall intra-hospital heterogeneity. METHODS: Simulated databases were created to modelise the heterogeneity of our hospital and computed to assess the reliance of indicator measurement. We used real data from a large teaching hospital having internal heterogeneity related to each department. RESULTS: Variance under heterogeneity was greater than under homogeneity (3- to 18-fold) leading to an increased size of the confidence interval (CI) (at 95%) from 9 (given Haute Autorité de Santé sources) to 22 (for greatest internal heterogeneity). CONCLUSIONS: The variations in a quality indicator can be explained by intra-institution heterogeneity and are not related to changes in the quality policy of the hospitals and may lead to errors in terms of pay for performance.

A caregiver educational program improves quality of life and burden for cancer patients and their caregivers: a randomised clinical trial.

PURPOSE OF THE RESEARCH: The French setting, including laws and guidelines, advocates greater involvement of informal caregivers in the care of cancer patients to protect the caregivers from depression, distress, and a decrease in their quality of life. This study aimed to assess the efficacy of a caregiver educational programme by measuring two outcomes: patients' and caregivers' quality of life and caregivers' burden. METHODS AND SAMPLE: A multicentre randomised controlled trial was performed in six oncology wards in French hospitals. Eligible patients had a cancer, a main caregiver, allowed their caregivers' involvement, and received an inclusion agreement by a doctor/psychologist dyad. The experimental group participated in an educational programme performed by nurses to improve their skills in meal support, nursing care, welfare care, or symptom management. The SF36 and the Zarit burden scales were used to measure quality of life and caregivers' burden at the beginning and at the end of the study. KEY RESULTS: 67 patients were randomised and 33 were included in the experimental group. Evolution scores, which measured the difference between baseline and final scores, showed an improvement in patients' and caregivers' quality of life and an alleviated burden for experimental group caregivers. CONCLUSIONS: An educational programme for caregivers encourages the involvement of patients, informal caregivers and health-care providers in a triangular relationship which enhances the quality of life of patients and caregivers alike and decreases caregivers' burden. Care organisation should therefore be rethought as a triangular relationship between patients, caregivers and health-care providers, with nurses as the mainstay.