Lean thinking in the hospital setting - Results of a systematic review of literature.

AIM: The aim of this study was to review experiences of use of the Lean methodology in the hospital setting and assess the impact of the interventions in terms of time of processes, productivity, effects on staff and patientd satisfaction. METHODS: PubMed, Scopus and CINAHL databases were searched to identify studies evaluating the lean methodology. Two reviewers screened the citations identified and extracted data according to the PRISMA methodology. RESULTS: In total, 635 citations were identified, of which 27 were included in the present review. Most studies showed a positive outcome related to the implementation of the Lean methodology and tools.

Highly-integrated programs for the prevention of obesity and overweight in children and adolescents: results from a systematic review and meta-analysis.

BACKGROUND: Since overweight and obesity has become epidemic in children and adolescents, the aim of this study was to determine the role of highly-integrated programs in preventing and reducing prevalence of children and adolescent obesity and overweight, even evaluating if this approach has properly been effective in communities with different determinants as in the Pacific Area. METHODS: According to PRISMA guidelines, a systematic review of literature was conducted and a meta-analysis was performed to compare obese/overweight prevalence between the intervention and the control group. RESULTS: We identified 23 studies describing 14 programs. For 11 out of 14 programs, obese/overweight prevalence changing from baseline were definable and meta-analysis of them showed a significant change of obese/overweight prevalence (-0.03; 95% CI = -0.04 to -0.01; P < 0.0001). Secondary outcomes as dietary (such as vegetable intake, carbonated beverages, fruit juice, drinks, healthful food consumption), physical activity and TV-time-spent was analyzed in many of the studies to define community readiness and behavioral changes. Macro-interventions, based on what was observed in our systematic review have a high potential to reach the entire population. CONCLUSION: Adoption of coordinated cross-sectoral, multi-component and multi-stakeholder initiatives to oppose obesity remains a challenge, but it is also desirable as one of the possible solutions to this major public health issue.

Does public reporting influence quality, patient and provider's perspective, market share and disparities? A review.

Background: Public reporting (PR) of healthcare (HC) provider's quality was proposed as a public health instrument for providing transparency and accountability in HC. Our aim was to assess the impact of PR on five main domains: quality improvement; patient choice, service utilization and market share; provider's perspective; patient experience; and unintended consequences. Methods: PubMed, Scopus, ISI WOS, and EconLit databases were searched to identify studies investigating relationships between PR and five main domains, published up to April 1, 2016. Results: Sixty-two papers published between 1988 and 2015 were included. Nineteen studies investigated quality improvement, 19 studies explored the unintended consequences of PR, 10 explored the effects on market share, 10 on patients' choice, 7 evaluated the provider's perspective, 4 economic outcome, 4 service utilization, 2 purchasers' use of PR and 2 studies explored patient experiences. The effect of PR was diverse throughout the studies-mostly positive on: patient experience (100%), quality improvement (63%), patient choice, service utilization and market share (46%); mixed on provider's perspective and economic outcome (27%) and mainly negative on unintended consequences (68%). Conclusions: Our research covering different outcomes and settings reported that PR is associated with changes in HC provider's behavior and can influence market share. Unintended consequences are a concern of PR and should be taken into account when allocating HC resources. The experiences collected in this paper could give a snapshot about the impact of PR on a HC user's perception of the providers' quality of care, helping them to make empowered choices.

Hospital efficiency: how to spend less maintaining quality?

INTRODUCTION: The recent global economic crisis is pushing governments worldwide to obtain a more explicit and urgent rationing of resources. The purpose of this study is to provide, through Data Envelopment Analysis (DEA), a methodological framework useful for investigating technical efficiency of hospital care. METHODS: To validate such framework, we compared 50 Italian public hospital trusts (AOs) to identify relative efficient using inputs and outputs from national databases. We also evaluated if, and how, efficiency is affected by various exogenous factors. RESULTS: On average, Italian AOs had an efficiency score of 77% (SD 0.12). Tobit regression model identified a positive association between efficiency and a lower case-mix index, being in the north of Italy, in a region with fiscal autonomy, with a higher public and a lower private expenditure on health as percentage of GDP. CONCLUSIONS: DEA may provide useful and especially objective information regarding the technical efficiency of hospital care and support hospital management and policy makers' decisions.

The impact of Public Reporting on clinical outcomes: a systematic review and meta-analysis.

BACKGROUND: To assess both qualitatively and quantitatively the impact of Public Reporting (PR) on clinical outcomes, we carried out a systematic review of published studies on this topic. METHODS: Pubmed, Web of Science and SCOPUS databases were searched to identify studies published from 1991 to 2014 that investigated the relationship between PR and clinical outcomes. Studies were considered eligible if they investigated the relationship between PR and clinical outcomes and comprehensively described the PR mechanism and the study design adopted. Among the clinical outcomes identified, meta-analysis was performed for overall mortality rate which quantitative data were exhaustively reported in a sufficient number of studies. Two reviewers conducted all data extraction independently and disagreements were resolved through discussion. The same reviewers evaluated also the quality of the studies using a GRADE approach. RESULTS: Twenty-seven studies were included. Mainly, the effect of PR on clinical outcomes was positive. Meta-analysis regarding overall mortality included, in a context of high heterogeneity, 10 studies with a total of 1,840,401 experimental events and 3,670,446 control events and resulted in a RR of 0.85 (95 % CI, 0.79-0.92). CONCLUSIONS: The introduction of PR programs at different levels of the healthcare sector is a challenging but rewarding public health strategy. Existing research covering different clinical outcomes supports the idea that PR could, in fact, stimulate providers to improve healthcare quality.

A meta-analysis-derived proposal for a clinical, ultrasonographic, and cytological scoring system to evaluate thyroid nodules: the "CUT" score.

The purpose of this study is to develop a new cancer risk score for preoperative assessment of thyroid nodules (TN) trying to reduce unnecessary thyroidectomies. On the basis of a recent meta-analysis of published literature, we assigned a matching value to the clinical (C) and ultrasonographic (U) features of TN with increased malignancy risk (MR). The created "CUT" score derived from "C+U" score, (CU[1-10] ), along with the five-tiered "T" (T[1-5] ), represents the cytologic result of the fine-needle aspiration. The C+U score was prospectively applied to 683 consecutive patients with 705 TN and validated through a ROC curve analysis. The CUT score was correlated with the histopathological diagnoses of 110 surgically resected TN. Fifty-five histologically benign TN had a mean C+U score of 2.4 versus 5.7 of 55 malignant TN (p < 0.001). Three categories were identified: low risk for C+U score ≤2.5 (MR: 9 %), intermediate risk for C+U score ≥2.75 and ≤5 (MR: 38 %), and high risk for C+U score ≥5.25 (MR: 95 %). Sensitivity and specificity were, respectively, 95 and 60 % for a cut-off value >2.5, and 69 and 96 % for >5. The "CUT" score can be easily applied, aiding clinicians in the evaluation of TN, especially in cases with indeterminate or repeated non-diagnostic FNA.

The impact of electronic health records on healthcare quality: a systematic review and meta-analysis.

OBJECTIVE: To assess the impact of electronic health record (EHR) on healthcare quality, we hence carried out a systematic review and meta-analysis of published studies on this topic. METHODS: PubMed, Web of Knowledge, Scopus and Cochrane Library databases were searched to identify studies that investigated the association between the EHR implementation and process or outcome indicators. Two reviewers screened identified citations and extracted data according to the PRISMA guidelines. Meta-analysis was performed using the random effects model for each indicator. Heterogeneity was quantified using the Cochran Q test and I2 statistics, and publication bias was assessed using the Egger's test. RESULTS: Of the 23 398 citations identified, 47 articles were included in the analysis. Meta-analysis showed an association between EHR use and a reduced documentation time with a difference in mean of -22.4% [95% confidence interval (CI) = -38.8 to -6.0%; P < 0.007]. EHR resulted also associated with a higher guideline adherence with a risk ratio (RR) of 1.33 (95% CI = 1.01 to 1.76; P = 0.049) and a lower number of medication errors with an overall RR of 0.46 (95% CI = 0.38 to 0.55; P < 0.001), and adverse drug effects (ADEs) with an overall RR of 0.66 (95% CI = 0.44 to 0.99; P = 0.045). No association with mortality was evident (P = 0.936). High heterogeneity among the studies was evident. Publication bias was not evident. CONCLUSIONS: EHR system, when properly implemented, can improve the quality of healthcare, increasing time efficiency and guideline adherence and reducing medication errors and ADEs. Strategies for EHR implementation should be therefore recommended and promoted.

Quantification of cancer risk of each clinical and ultrasonographic suspicious feature of thyroid nodules: a systematic review and meta-analysis.

OBJECTIVE: In order to quantify the risk of malignancy of clinical and ultrasonographic features of thyroid nodules (TNs), we did a systematic review and meta-analysis of published studies. METHODS: We did a literature search in MEDLINE for studies published from 1st January 1989 until 31st December 2012. Studies were considered eligible if they investigated the association between at least one clinical/ultrasonographic feature and the risk of malignancy, did not have exclusion criteria for the detected nodules, had histologically confirmed the diagnoses of malignancy, and had a univariable analysis available. Two reviewers independently extracted data on study characteristics and outcomes. RESULTS: The meta-analysis included 41 studies, for a total of 29678 TN. A higher risk of malignancy expressed in odds ratio (OR) was found for the following: nodule height greater than width (OR: 10.15), absent halo sign (OR: 7.14), microcalcifications (OR: 6.76), irregular margins (OR: 6.12), hypoechogenicity (OR: 5.07), solid nodule structure (OR: 4.69), intranodular vascularization (OR: 3.76), family history of thyroid carcinoma (OR: 2.29), nodule size ≥4 cm (OR: 1.63), single nodule (OR: 1.43), history of head/neck irradiation (OR: 1.29), and male gender (OR: 1.22). Interestingly, meta-regression analysis showed a higher risk of malignancy for hypoechoic nodules in iodine-sufficient than in iodine-deficient geographical areas. CONCLUSIONS: The current meta-analysis verified and weighed out each suspicious clinical and ultrasonographic TN feature. The highest risk was found for nodule height greater than width, absent halo sign, and microcalcifications for ultrasonographic features and family history of thyroid carcinoma for clinical features. A meta-analysis-derived grading system of TN malignancy risk, validated on a large prospective cohort, could be a useful tool in TN diagnostic work-up.