Mixed Methods Lot Quality Assurance Sampling: A novel, rapid methodology to inform equity focused maternal health programming in rural Rajasthan, India.

India has experienced a significant increase in facility-based delivery (FBD) coverage and reduction in maternal mortality. Nevertheless, India continues to have high levels of maternal health inequity. Improving equity requires data collection methods that can produce a better contextual understanding of how vulnerable populations access and interact with the health care system at a local level. While large population-level surveys are valuable, they are resource intensive and often lack the contextual specificity and timeliness to be useful for local health programming. Qualitative methods can be resource intensive and may lack generalizability. We describe an innovative mixed-methods application of Large Country-Lot Quality Assurance Sampling (LC-LQAS) that provides local coverage data and qualitative insights for both FBD and antenatal care (ANC) in a low-cost and timely manner that is useful for health care providers working in specific contexts. LC-LQAS is a version of LQAS that combines LQAS for local level classification with multistage cluster sampling to obtain precise regional or national coverage estimates. We integrated qualitative questions to uncover mothers' experiences accessing maternal health care in the rural district of Sri Ganganagar, Rajasthan, India. We interviewed 313 recently delivered, low-income women in 18 subdistricts. All respondents participated in both qualitative and quantitative components. All subdistricts were classified as having high FBD coverage with the upper threshold set at 85%, suggesting that improved coverage has extended to vulnerable women. However, only two subdistricts were classified as high ANC coverage with the upper threshold set at 40%. Qualitative data revealed a severe lack of agency among respondents and that household norms of care seeking influenced uptake of ANC and FBD. We additionally report on implementation outcomes (acceptability, feasibility, appropriateness, effectiveness, fidelity, and cost) and how study results informed the programs of a local health non-profit.

[Medical biology in the face of the evolution of health care needs]. / Rapport des Académies nationales de médecine et de pharmacie sur la biologie médicale La biologie médicale face aux défis de l'évolution des besoins de santé.

Since the publication of the ordinance of January 13th 2010, ratified by the law of May 30th 2013, medical biology in France has undergone a massive restructuration with the emergence of groups of several hundred laboratories. This evolution, which leads to a considerable reduction in the number of structures, causes numerous problems related to increased industrialization and financialization, difficulties of accreditation and disappearance of the proximity link between the biologist and the prescriber or the patient. It also leads to a clear disaffection of students, especially medical students, for this specialty whose medical character has been clearly affirmed by the law. This report takes stock of the current situation of medical biology and makes recommendations to strengthen the role of the medical biologist in the health system and patients' care.

Examining Trends in Obstetric Quality Measures for Monitoring Health Care Disparities.

BACKGROUND: Elective delivery (ED) before 39 weeks, low-risk cesarean delivery, and episiotomy are routinely reported obstetric quality measures and have been the focus of quality improvement initiatives over the past decade. OBJECTIVE: To estimate trends and differences in obstetric quality measures by race/ethnicity. RESEARCH DESIGN: We used 2008-2014 linked birth certificate-hospital discharge data from New York City to measure ED before 39 gestational weeks (ED <39), low-risk cesarean, and episiotomy by race/ethnicity. Measures were following the Joint Commission and National Quality Forum specifications. Average annual percent change (AAPC) was estimated using Poisson regression for each measure by race/ethnicity. Risk differences (RD) for non-Hispanic black women, Hispanic women, and Asian women compared with non-Hispanic white women were calculated. RESULTS: ED<39 decreased among whites [AAPC=-2.7; 95% confidence interval (CI), -3.7 to -1.7), while it increased among blacks (AAPC=1.3; 95% CI, 0.1-2.6) and Hispanics (AAPC=2.4; 95% CI, 1.4-3.4). Low-risk cesarean decreased among whites (AAPC=-2.8; 95% CI, -4.6 to -1.0), and episiotomy decreased among all groups. In 2008, white women had higher risk of most measures, but by 2014 incidence of ED<39 was increased among Hispanics (RD=2/100 deliveries; 95% CI, 2-4) and low-risk cesarean was increased among blacks (RD=3/100; 95% CI, 0.5-6), compared with whites. Incidence of episiotomy was lower among blacks and Hispanics than whites, and higher among Asian women throughout the study period. CONCLUSIONS: Existing measures do not adequately assess health care disparities due to modest risk differences; nonetheless, continued monitoring of trends is warranted to detect possible emergent disparities.

[E-Health in diagnosis and therapy of mental disorders : Will therapists soon become superfluous?] / E-Health in Diagnostik und Therapie psychischer Störungen : Werden Therapeuten bald überflüssig?

Digital media, online programs, and electronic health systems are available and easily accessible for diagnostic, prevention, and intervention of somatic and psychiatric disorders. These modern tools can assess objective as well as subjective information about acute symptoms, wellbeing, life quality, sleep, physiological indicators, etc. Wearables and apps collect data over days and weeks in the real world of subjects. This information can be used to document baselines as well as changes over time influenced by events or interventions. Online treatment programs provide information for education about symptoms, course, origin, and treatment options of a disorder. They also support a patient's self-help via self-management, exercises, and techniques. We illustrate and discuss modern diagnostic and therapeutic eHealth options. We also review the empirical evidence for online interventions and refer to typical examples. Most studies have been conducted with subjects suffering from depression and anxiety. Electronic health systems do not work just by recommending a program or providing access to an online platform. Patients need to be motivated to lock in and work with a program. They need support and guidance through online programs. Therefore, we claim that therapists need to become experts in digital media and electronic health systems to support patients and to integrate apps and online programs into their treatment.

Quality of training in radiation oncology in Germany: where do we stand? : Results from a 2016/2017 survey performed by the working group "young DEGRO" of the German society of radiation oncology (DEGRO).

PURPOSE: To evaluate the current situation of young radiation oncologists in Germany with regard to the contents and quality of training and level of knowledge, as well as their working conditions and professional satisfaction. METHODS: From June 2016 to February 2017, a survey was conducted by the young DEGRO (yDEGRO) using an online platform. The questionnaire consisted of 28 items examining a broad range of aspects influencing residency. There were 96 completed questionnaires RESULTS: 83% of participants stated to be very or mostly pleased with their residency training. Moderate working hours and a good colleagueship contribute to a comfortable working environment. Level of knowledge regarding the most common tumor sites (i.e. palliative indications, lung, head and neck, brain, breast, prostate) was pleasing. Radiochemotherapy embodies a cornerstone in training. Modern techniques such as intensity-modulated radiotherapy (IMRT) and stereotactic procedures are now in widespread use. Education for rare indications and center-based procedures offers room for improvement. CONCLUSION: Radiation oncology remains an attractive and versatile specialty with favorable working conditions. Continuing surveys in future years will be a valuable measuring tool to set further priorities in order to preserve and improve quality of training.

[10 years of external quality assurance in dialysis in Germany: Results and future prospects]. / 10 Jahre Qualitätssicherung Dialyse in Deutschland ­ Bilanz und Ausblick.

BACKGROUND: In 2006, the Federal Joint Committee introduced a quality assurance programme for ambulatory dialysis treatment in Germany. Regarding the impact of chronic dialysis treatment on the quality of life of patients and on health care costs, quality assurance in dialysis is considered highly relevant. The directive on Quality Assurance in Dialysis (QSD-RL) established an external quality assurance programme on the basis of the assessment of certain quality parameters combined with an internal quality management system based on benchmarking parameters in all dialysis practices and centres. Data on quality parameters are collected and analysed quarterly. Regional associations of statutory health insurance physicians take responsibility for quality improvement measures and sanctions. This article aims to provide an overview of the development of quality parameters from 2008 to 2015. METHODS: We analysed the summarised annual quality reports published on the website of the Federal Joint Committee between 2009 and 2016. We present results on the so-called core quality parameters duration and frequency of dialysis sessions (both for haemodialysis patients), wKt/V for peritoneal dialysis patients, and percentage of haemodialysis patients with central venous catheters which has only been measured since 2014. RESULTS AND CONCLUSIONS: In 2015, 92,000 patients received outpatient dialysis. Between 2008 and 2015, the results for the core quality parameters duration and frequency of haemodialysis improved while the results for wKt/V seemingly show an unfavourable trend. The percentage of patients with central venous catheters appears to be quite high, and thus indicates that there is potential for quality improvement. FUTURE PERSPECTIVES: For the future, the Federal Joint Committee has resolved to merge the quality assurance programmes in dialysis and in kidney transplantation into a newly designed programme that has the potential to follow patients through all stages and kinds of renal replacement therapy and to focus on further aspects of treatment quality.

EQ-5D and the EuroQol Group: Past, Present and Future.

Over the period 1987-1991 an inter-disciplinary five-country group developed the EuroQol instrument, a five-dimensional three-level generic measure subsequently termed the 'EQ-5D'. It was designed to measure and value health status. The salient features of its development and its consolidation and expansion are discussed. Initial expansion came, in particular, in the form of new language versions. Their development raised translation and semantic issues, experience with which helped feed into the design of two further instruments, the EQ-5D-5L and the youth version EQ-5D-Y. The expanded usage across clinical programmes, disease and condition areas, population surveys, patient-reported outcomes, and value sets is outlined. Valuation has been of continued relevance for the Group as this has allowed its instruments to be utilised as part of the economic appraisal of health programmes and their incorporation into health technology assessments. The future of the Group is considered in the context of: (1) its scientific strategy, (2) changes in the external environment affecting the demand for EQ-5D, and (3) a variety of issues it is facing in the context of the design of the instrument, its use in health technology assessment, and potential new uses for EQ-5D outside of clinical trials and technology appraisal.

A new era of quality measurement in rheumatology: electronic clinical quality measures and national registries.

PURPOSE OF REVIEW: This article reviews the evolution of quality measurement in rheumatology, highlighting new health-information technology infrastructure and standards that are enabling unprecedented innovation in this field. RECENT FINDINGS: Spurred by landmark legislation that ties physician payment to value, the widespread use of electronic health records, and standards such as the Quality Data Model, quality measurement in rheumatology is rapidly evolving. Rather than relying on retrospective assessments of care gathered through administrative claims or manual chart abstraction, new electronic clinical quality measures (eCQMs) allow automated data capture from electronic health records. At the same time, qualified clinical data registries, like the American College of Rheumatology's Rheumatology Informatics System for Effectiveness registry, are enabling large-scale implementation of eCQMs across national electronic health record networks with real-time performance feedback to clinicians. Although successful examples of eCQM development and implementation in rheumatology and other fields exist, there also remain challenges, such as lack of health system data interoperability and problems with measure accuracy. SUMMARY: Quality measurement and improvement is increasingly an essential component of rheumatology practice. Advances in health information technology are likely to continue to make implementation of eCQMs easier and measurement more clinically meaningful and accurate in coming years.

Improving performance of an accountable care organization on a quality measure assessing ß-blocker use in systolic heart failure.

PURPOSE: The implementation and outcomes are described for a clinical pharmacist-generated initiative to improve the performance of a Medicare Pioneer accountable care organization (ACO) quality measure evaluating the percentage of patients at least 18 years of age with heart failure and a left ventricular ejection fraction (LVEF) of less than 40% who are prescribed with an evidence-based ß-blocker (carvedilol, metoprolol succinate, or bisoprolol). SUMMARY: Atrius Health clinical pharmacists developed several educational documents to facilitate appropriate prescribing of evidence-based therapies in patients with heart failure. After educating clinicians, clinical pharmacists reviewed patient charts to determine eligibility for initiating or switching to evidence-based ß-blocker therapy. Medicare Pioneer ACO patients 18-85 years of age with heart failure and a current or prior LVEF of less than 40% were reviewed. Patients had a current prescription for metoprolol tartrate, atenolol, or no ß-blocker. Patients were considered ineligible if they had a documented contraindication or intolerance to ß-blocker therapy or were clinically unstable. Recommendations to initiate or switch to an appropriate ß-blocker were sent electronically by a clinical pharmacist to an eligible patient's treating physician before a scheduled office visit. In approximately three months, 48 patients underwent chart review by a clinical pharmacist. Performance improved by 8% after the implementation, with 82% of eligible patients achieving the quality measure in 2014-an increase from 74% in 2013. CONCLUSION: The performance on a Medicare Pioneer ACO quality measure evaluating ß-blocker use in systolic heart failure improved in a one-year period after a clinical pharmacist-generated initiative was implemented at Atrius Health practice sites.

Rehabilitation - a new approach. Part four: a new paradigm, and its implications.

This editorial proposes changes in healthcare services that should greatly improve the health status of all patients with disability. The main premises are that: rehabilitation usually involves many actions delivered by many people from different organisations over a prolonged period; specific rehabilitation actions cover a wide range of professional activities, with face to face therapy only being one; and the primary patient activity that improves function is practice of personally relevant activities in a safe environment. This editorial argues that: rehabilitation should occur at all times and in all settings, in parallel with medical care in order to maximise recovery and to avoid loss of fitness, skills and confidence associated with rest and being cared for; hospitals and other healthcare settings should adapt the environment to encourage practice of activities at all times; and that measuring rehabilitation, whether in research or for re-imbursement, should not simply consider face-to-face 'therapy time' but must include: all the other important activities undertaken by the team; 'structures' such as the appropriateness of the environment; and a process measure of the time spent by patients undertaking activities.

The Development and Validation of a Quality Assessment and Rating of Technique for Injections of the Spine (AQUARIUS).

BACKGROUND AND OBJECTIVES: Systematic reviews evaluate the utility of procedural interventions of the spine, including epidural steroid injections (ESIs). However, existing quality assessment tools either fail to account for proper technical quality and patient selection or are not validated. We developed and validated a simple scale for ESIs to provide a quality assessment and rating of technique for injections of the spine (AQUARIUS). METHODS: Seven experts generated items iteratively based on prior ESI technique studies and professional judgment. Following testing for face and content validity, a 17-item instrument was used by 8 raters from 2 different backgrounds to assess 12 randomized controlled trials, selected from 3 different categories. Using frequency of assessment, a 12-item instrument was also generated. Both instruments underwent reliability (intraclass correlation coefficient), validity (ability to distinguish "low," "random," and "high" study categories), and diagnostic accuracy (receiver operating characteristics) testing. RESULTS: Both 17- and 12-item instruments were scored consistently by raters regardless of background, with overall intraclass correlation coefficients of 0.72 (95% confidence interval [CI], 0.53-0.89) and 0.71 (95% CI, 0.51-0.89), respectively. Both instruments discriminated between clinical trials from all 3 categories. Diagnostic accuracy was similar for the 2 instruments, with areas under receiver operating characteristic curves of 0.89 (95% CI, 0.82-0.96) and 0.90 (95% CI, 0.82-0.97), respectively. CONCLUSIONS: The instrument in both 17- and 12-item formats demonstrates good reliability and diagnostic accuracy in rating ESI studies. As a complement to other tools that assess bias, the instrument may improve the ability to evaluate evidence for systematic reviews and improve clinical trial design.

[Modern principles of the geriatric analysis in medicine].

The offered methodological principles of the geriatric analysis in medicine enables to plan economic parameters of social protection of the population, necessary amount of medical help financing, to define a structure of the qualified medical personnel training. It is shown that personal health and cognitive longevity of the person depend on the adequate system geriatric analysis and use of biological parameters monitoring in time. That allows estimate efficiency of the combined individual treatment. The geriatric analysis and in particular its genetic-mathematical component aimed at reliability and objectivity of an estimation of the person life expectancy in the country and in region due to the account of influence of mutagen factors as on a gene of the person during his live, and on a population as a whole.