Avaliação da cobertura vacinal da poliomielite nos estados da região sul, com foco no município de Pato Branco, entre os anos de 2009-2019 / Assessment of polio vaccination coverage in the southern states, focusing on the municipality of Pato Branco, from 2009-2019 / Evaluación de la cobertura de vacunación contra la poliomielitis en los estados de la región sur, con enfoque en el municipio de Pato Branco, entre los años 2009-2019

Objetivo: Analisar a taxa de cobertura vacinal da poliomielite em relação às metas de vacinação de 95% da população-alvo, estabelecidas pelo Ministério da Saúde, com base nos registros de imunização do DATASUS nos estados do Paraná, Santa Catarina e Rio Grande do Sul, que compõem a região sul do Brasil, e na cidade de Pato Branco, PR. Métodos: Estudo descritivo de abordagem quantitativa referente à cobertura vacinal da Poliomielite nos estados da região sul e no município de Pato Branco, PR com resultados da cobertura avaliados quanto ao alcance das metas estabelecidas pelo Ministério da Saúde e comparado o desempenho entre os estados e o município no período de 2009 a 2019. Os dados foram recolhidos da seção de Imunizações do DATASUS, o departamento de informática do Sistema Único de Saúde do Brasil. Resultados: No período analisado, o município de Pato Branco se manteve com uma taxa satisfatória em relação à meta estabelecida pelo Ministério da Saúde, exceto nos anos de 2017 e 2018, onde ficou abaixo da meta em cerca de 3% e 11%, respectivamente. Em relação aos estados do sul, o estado do Paraná mostrou-se abaixo da meta de cobertura vacinal recomendada na maioria dos anos estudados, com a menor cobertura ocorrendo em 2017, ficando 15% abaixo do esperado; o estado de Santa Catarina, apesar de apresentar queda desde o ano de 2014, apresentou os melhores índices de cobertura vacinal, com a maior taxa de queda de cobertura no ano de 2018 com cerca de 7%; e o estado do Rio Grande do Sul se apresentou como o estado com o pior desempenho na região, demonstrando quedas significativas da cobertura desde 2010, com menor taxa de vacinação em 2017, ficando 18% abaixo do esperado. Conclusões: Pode-se observar uma queda nos valores da cobertura vacinal entre os anos de 2009 a 2019, tanto no município de Pato Branco, PR, quanto nos estados do Paraná, Santa Catarina e Rio Grande do Sul, algo que é motivo de crescente preocupação pelos serviços de saúde do país devido à possibilidade de reintrodução da doença no território nacional. Ressalta-se, então, a necessidade de criação de estratégias eficazes para o combate das quedas das taxas de cobertura vacinal no país.

Objective: To analyze the rate of polio vaccination coverage in relation to the vaccination goals of 95% of the target population, set by the Ministry of Health, based on DATASUS immunization records in the states of Paraná, Santa Catarina, and Rio Grande do Sul, which make up the southern region of Brazil, and in the city of Pato Branco, PR. Methods: A descriptive study of quantitative approach regarding the vaccination coverage of Poliomyelitis in the states of the southern region and in the municipality of Pato Branco, PR with coverage results evaluated as to the achievement of the goals set by the Ministry of Health and compared performance between the states and the municipality in the period from 2009 to 2019. The data were collected from the Immunizations section of DATASUS, the computer department of the Brazilian Unified Health System. Results: In the period analyzed, the municipality of Pato Branco remained with a satisfactory rate in relation to the target set by the Ministry of Health, except in the years 2017 and 2018, where it was below the target by about 3% and 11%, respectively. Regarding the southern states, the state of Paraná showed below the recommended vaccine coverage target in most of the years studied, with the lowest coverage occurring in 2017, being 15% below expected; the state of Santa Catarina, despite showing a drop since the year 2014, showed the best rates of vaccine coverage, with the highest rate of drop in coverage in the year 2018 with about 7%; and the state of Rio Grande do Sul presented itself as the state with the worst performance in the region, showing significant drops in coverage since 2010, with the lowest rate of vaccination in 2017, being 18% below expectations. Conclusions: A drop in vaccination coverage values can be observed between the years 2009 and 2019, both in the municipality of Pato Branco, PR, and in the states of Paraná, Santa Catarina, and Rio Grande do Sul, something that is a cause of growing concern for the country's health services due to the possibility of reintroduction of the disease in the national territory. Therefore, the need to create effective strategies to combat the declines in vaccination coverage rates in the country is highlighted.

Objetivo: Analizar la tasa de cobertura de vacunación antipoliomielítica en relación con las metas de vacunación del 95% de la población objetivo, establecidas por el Ministerio de Salud, a partir de los registros de inmunización DATASUS en los estados de Paraná, Santa Catarina y Rio Grande do Sul, que conforman la región sur de Brasil, y en la ciudad de Pato Branco, PR. Métodos: Estudio descriptivo de abordaje cuantitativo referente a la cobertura vacunal de la Poliomielitis en los estados de la región sur y en el municipio de Pato Branco, PR con resultados de la cobertura evaluados en cuanto al alcance de las metas establecidas por el Ministerio de Salud y comparado el rendimiento entre los estados y el municipio en el período de 2009 a 2019. Los datos se recogieron de la sección de Inmunizaciones de DATASUS, el departamento de informática del Sistema Único de Salud de Brasil. Resultados: En el período analizado, el municipio de Pato Branco se mantuvo con una tasa satisfactoria en relación a la meta establecida por el Ministerio de Salud, excepto en los años 2017 y 2018, donde estuvo por debajo de la meta en cerca de 3% y 11%, respectivamente. En lo que respecta a los estados del sur, el estado de Paraná se mostró por debajo de la meta de cobertura vacunal recomendada en la mayoría de los años estudiados, siendo la cobertura más baja la que se produjo en el año 2017, estando un 15% por debajo de lo esperado; el estado de Santa Catarina, a pesar de mostrar una caída desde el año 2014, mostró los mejores índices de cobertura vacunal, siendo la mayor tasa de caída de la cobertura en el año 2018 con cerca de un 7%; y el estado de Río Grande do Sul se presentó como el estado con peor desempeño en la región, demostrando caídas significativas en la cobertura desde 2010, con la tasa de vacunación más baja en 2017, siendo un 18% por debajo de lo esperado. Conclusiones: Se observa una caída en los valores de las coberturas de vacunación entre los años 2009 y 2019, tanto en el municipio de Pato Branco, PR, como en los estados de Paraná, Santa Catarina y Rio Grande do Sul, algo que es motivo de creciente preocupación para los servicios de salud del país debido a la posibilidad de reintroducción de la enfermedad en el territorio nacional. Por lo tanto, se destaca la necesidad de crear estrategias eficaces para combatir el descenso de las tasas de cobertura de vacunación en el país.

The 2018 Merit-based Incentive Payment System: Participation, Performance, and Payment Across Specialties.

BACKGROUND: The Merit-based Incentive Payment System (MIPS) incorporates financial incentives and penalties intended to drive clinicians towards value-based purchasing, including alternative payment models (APMs). Newly available Medicare-approved qualified clinical data registries (QCDRs) offer specialty-specific quality measures for clinician reporting, yet their impact on clinician performance and payment adjustments remains unknown. OBJECTIVES: We sought to characterize clinician participation, performance, and payment adjustments in the MIPS program across specialties, with a focus on clinician use of QCDRs. RESEARCH DESIGN: We performed a cross-sectional analysis of the 2018 MIPS program. RESULTS: During the 2018 performance year, 558,296 clinicians participated in the MIPS program across the 35 specialties assessed. Clinicians reporting as individuals had lower overall MIPS performance scores (median [interquartile range (IQR)], 80.0 [39.4-98.4] points) than those reporting as groups (median [IQR], 96.3 [76.9-100.0] points), who in turn had lower adjustments than clinicians reporting within MIPS APMs (median [IQR], 100.0 [100.0-100.0] points) (P<0.001). Clinicians reporting as individuals had lower payment adjustments (median [IQR], +0.7% [0.1%-1.6%]) than those reporting as groups (median [IQR], +1.5% [0.6%-1.7%]), who in turn had lower adjustments than clinicians reporting within MIPS APMs (median [IQR], +1.7% [1.7%-1.7%]) (P<0.001). Within a subpopulation of 202,685 clinicians across 12 specialties commonly using QCDRs, clinicians had overall MIPS performance scores and payment adjustments that were significantly greater if reporting at least 1 QCDR measure compared with those not reporting any QCDR measures. CONCLUSIONS: Collectively, these findings highlight that performance score and payment adjustments varied by reporting affiliation and QCDR use in the 2018 MIPS.

Validação de indicadores para monitoramento da qualidade do pré-natal / Validación de indicadores para el seguimiento de la calidad de la atención prenatal / Validation of indicators for monitoring the quality of prenatal care

Resumo Objetivo validar indicadores para o monitoramento da qualidade da assistência pré-natal. Método estudo metodológico, com 11 especialistas da Linha de Cuidado à Saúde Materna e Infantil do Paraná, realizado em 2020. Os indicadores foram organizados em domínios de um modelo lógico e na tríade estrutura, processo e resultado. Analisado Taxa de Concordância, Razão de Validade de Conteúdo, Índice de Validade de Conteúdo e confiabilidade pelo Alfa de Cronbach. Resultados elaboração de 35 indicadores e, após os procedimentos de validação foram readequados quanto a clareza, dois foram excluídos. Apresentaram confiabilidade excelente para clareza e relevância da estrutura (0,94), do processo (0,98) e do resultado (0,94); bem como, em relação aos domínios do modelo lógico de entradas (0,96), atividades (0,86), saídas (0,98), resultados (0,86) e impacto (0,96). Conclusão os indicadores apresentam validade e confiabilidade para da qualidade do pré-natal, sob a ótica do monitoramento e da qualidade em saúde. Implicações para a Prática o constructo apresenta flexibilidade de aplicação para diversas dimensões territoriais como municípios, regionais de saúde e estado.

Resumen Objetivo validar indicadores para el seguimiento de la calidad de la atención prenatal. Método estudio metodológico, con 11 especialistas de la Línea de Atención Materno infantil de Paraná, indicadores organizados en dominios de un modelo lógico y en la organización de la tríada estructura, proceso y resultado, realizado en 2020. Tasa de Concordancia Calculada, Razón de Validez de Contenido, Índice de Validez de Contenido; y confiabilidad por Alfa de Cronbach. Resultados Se elaboraron 35 indicadores, que luego de reajustar los procedimientos de validación para mayor claridad, se excluyeron dos. Mostró una excelente confiabilidad para la claridad y relevancia de la estructura (0.94), el proceso (0.98) y el resultado (0.94); así como en relación con los dominios del modelo lógico de insumos (0,96), actividades (0,86), productos (0,98), resultados (0,86) e impacto (0,96). Conclusión los indicadores son válidos y confiables para evaluar la calidad de la atención prenatal, reflejando el impacto de esta atención en la gestión de la calidad. Implicaciones para la práctica El constructo presenta flexibilidad de aplicación para varias dimensiones territoriales como municipios, salud regional y estadual.

Abstract Objective to validate indicators for monitoring the quality of prenatal care. Method methodological study conducted in 2020 with 11 specialists of the maternal and child health care line of Paraná. The indicators were organized in domains of a logical model and in the triad structure, process, and result. The calculated agreement rate, content validity ratio, content validity index, and Cronbach's alpha reliability were analyzed. Results 35 indicators were elaborated, which after the validation procedures were readjusted for clarity, two were excluded. It showed excellent reliability for clarity and relevance of the structure (0.94), process (0.98), and result (0.94), as well as in relation to the domains of the logical model of inputs (0.96), activities (0.86), outputs (0.98), results (0.86), and impact (0.96). Conclusion the indicators are valid and reliable for evaluating the quality of prenatal care, reflecting the impact of this care on quality management. Implications for Practice The construct presents flexibility of application for several territorial dimensions such as municipalities, regional health, and state.

Association Between the Physician Quality Score in the Merit-Based Incentive Payment System and Hospital Performance in Hospital Compare in the First Year of the Program.

Importance: The scientific validity of the Merit-Based Incentive Payment System (MIPS) quality score as a measure of hospital-level patient outcomes is unknown. Objective: To examine whether better physician performance on the MIPS quality score is associated with better hospital outcomes. Design, Setting, and Participants: This cross-sectional study of 38 830 physicians used data from the Centers for Medicare & Medicaid Services (CMS) Physician Compare (2017) merged with CMS Hospital Compare data. Data analysis was conducted from September to November 2020. Main Outcomes and Measures: Linear regression was used to examine the association between physician MIPS quality scores aggregated at the hospital level and hospitalwide measures of (1) postoperative complications, (2) failure to rescue, (3) individual postoperative complications, and (4) readmissions. Results: The study cohort of 38 830 clinicians (5198 [14.6%] women; 12 103 [31.6%] with 11-20 years in practice) included 6580 (17.2%) general surgeons, 8978 (23.4%) orthopedic surgeons, 1617 (4.2%) vascular surgeons, 582 (1.5%) cardiac surgeons, 904 (2.4%) thoracic surgeons, 18 149 (47.4%) anesthesiologists, and 1520 (4.0%) intensivists at 3055 hospitals. The MIPS quality score was not associated with the hospital composite rate of postoperative complications. MIPS quality scores for vascular surgeons in the 11th to 25th percentile, compared with those in the 51st to 100th percentile, were associated with a 0.55-percentage point higher hospital rate of failure to rescue (95% CI, 0.06-1.04 percentage points; P = .03). MIPS quality scores for cardiac surgeons in the 1st to 10th percentile, compared with those in the 51st to 100th percentile, were associated with a 0.41-percentage point higher hospital coronary artery bypass graft (CABG) mortality rate (95% CI, 0.10-0.71 percentage points; P = .01). MIPS quality scores for cardiac surgeons in the 1st to 10th percentile and 11th to 25th percentile, compared with those in the 51st to 100th percentile, were associated with 0.65-percentage point (95% CI, 0.013-1.16 percentage points; P = .02) and 0.48-percentage point (95% CI, 0.07-0.90 percentage points; P = .02) higher hospital CABG readmission rates, respectively. Conclusions and Relevance: In this study, better performance on the physician MIPS quality score was associated with better hospital surgical outcomes for some physician specialties during the first year of MIPS.

Avaliação da eficiência das unidades de urgência e emergência: Análise Envoltória de Dados / Efficiency assessment of urgency and emergency units: Data Envelopment Analysis

Presumindo-se que os gestores de unidade de saúde do SUS tenham dois objetivos principais: 1. maximizar o número de internações (modelo orientado à produção), 2. reduzir os recursos consumidos em excesso, ou seja, quanto poderia reduzir em número de leitos, pessoal e valor de AIH para produzir as mesmas altas (modelo orientado à redução de consumo). O índice de eficiência, que assume o valor no intervalo de [0, 1], é capaz de fazer a relação entre os resultados atingidos pelas unidades de saúde no sentido de minimizar gastos/consumos e maximizar a produção. A análise envoltória de dados (DEA ­ do inglês data envelopment analysis) é uma técnica de pesquisa operacional, cujo objetivo é analisar comparativamente unidades independentes no que se refere ao desempenho relativo. Uma unidade de tomada de decisão (DMU ­ do inglês Decision Making Units) é considerada eficiente se pertencer à fronteira de eficiência dos dados, ou seja, quanto mais próximo a 1, mais eficiente é considerada a DMU, sendo que valores iguais a 1 indicam eficiência máxima. A análise envoltória de dados (DEA ­ do inglês data envelopment analysis) é uma técnica de pesquisa operacional, cujo objetivo é analisar comparativamente unidades independentes no que se refere ao desempenho relativo. Uma unidade de tomada de decisão (DMU ­ do inglês Decision Making Units) é considerada eficiente se pertencer à fronteira de eficiência dos dados, ou seja, quanto mais próximo a 1, mais eficiente é considerada a DMU, sendo que valores iguais a 1 indicam eficiência máxima

Assuming that SUS health unit managers have two main objectives: 1. Maximize the number of hospitalizations (production-oriented model),2. reduce the resources consumed in excess, that is, how much could be reduced in the number of beds, personnel and value of AIH to produce the same discharges (model oriented to the reduction of consumption). The efficiency index, which assumes the value in the range of [0, 1], is able to make the relationship between the results achieved by the health units in order to minimize expenses/consumptions and maximize production. Data envelopment analysis (DEA) is an operations research technique whose objective is to comparatively analyze independent units with regard to relative performance. A decision making unit (DMU) is considered efficient if it belongs to the data efficiency frontier, that is, the closer to 1, the more efficient the DMU is considered, with values ​​equal to 1 indicating maximum efficiency. Data envelopment analysis (DEA) is an operations research technique whose objective is to comparatively analyze independent units with regard to relative performance. A decision making unit (DMU) is considered efficient if it belongs to the data efficiency frontier, that is, the closer to 1, the more efficient the DMU is considered, with values ​​equal to 1 indicating maximum efficiency

Incorporating Present-on-Admission Indicators in Medicare Claims to Inform Hospital Quality Measure Risk Adjustment Models.

Importance: Present-on-admission (POA) indicators in administrative claims data allow researchers to distinguish between preexisting conditions and those acquired during a hospital stay. The impact of adding POA information to claims-based measures of hospital quality has not yet been investigated to better understand patient underlying risk factors in the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision setting. Objective: To assess POA indicator use on Medicare claims and to assess the hospital- and patient-level outcomes associated with incorporating POA indicators in identifying risk factors for publicly reported outcome measures used by the Centers for Medicare & Medicaid Services (CMS). Design, Setting, and Participants: This comparative effectiveness study used national CMS claims data between July 1, 2015, and June 30, 2018. Six hospital quality measures assessing readmission and mortality outcomes were modified to include POA indicators in risk adjustment models. The models using POA were then compared with models using the existing complications-of-care algorithm to evaluate changes in risk model performance. Patient claims data were included for all Medicare fee-for-service and Veterans Administration beneficiaries aged 65 years or older with inpatient hospitalizations for acute myocardial infarction, heart failure, or pneumonia within the measurement period. Data were analyzed between September 2019 and March 2020. Main Outcomes and Measures: Changes in patient-level (C statistics) and hospital-level (quintile shifts in risk-standardized outcome rates) model performance after including POA indicators in risk adjustment. Results: Data from a total of 6 027 988 index admissions were included for analysis, ranging from 491 366 admissions (269 209 [54.8%] men; mean [SD] age, 78.2 [8.3] years) for the acute myocardial infarction mortality outcome measure to 1 395 870 admissions (677 158 [48.5%] men; mean [SD] age, 80.3 [8.7] years) for the pneumonia readmission measure. Use of POA indicators was associated with improvements in risk adjustment model performance, particularly for mortality measures (eg, the C statistic increased from 0.728 [95% CI, 0.726-0.730] to 0.774 [95% CI, 0.773-0.776] when incorporating POA indicators into the acute myocardial infarction mortality measure). Conclusions and Relevance: The findings of this quality improvement study suggest that leveraging POA indicators in the risk adjustment methodology for hospital quality outcome measures may help to more fully capture patients' risk factors and improve overall model performance. Incorporating POA indicators does not require extra effort on the part of hospitals and would be easy to implement in publicly reported quality outcome measures.

Analysis of cesarean section rates in two German hospitals applying the 10-Group Classification System.

OBJECTIVES: In Germany, cesarean section (CS) rates more than doubled within the past two decades. For analysis, auditing and inter-hospital comparison, the 10-Group Classification System (TGCS) is recommended. We used the TGCS to analyze CS rates in two German hospitals of different levels of care. METHODS: From October 2017 to September 2018, data were prospectively collected. Unit A is a level three university hospital, unit B a level one district hospital. The German birth registry was used for comparison with national data. We performed two-sample Z tests and bootstrapping to compare aggregated (unit A + B) with national data and unit A with unit B. RESULTS: In both datasets (national data and aggregated data unit A + B), Robson group (RG) 5 was the largest contributor to the overall CS rate. Compared to national data, group sizes in RG 1 and 3 were significantly smaller in the units under investigation, RG 8 and 10 significantly larger. Total CS rates between the two units differed (40.7 vs. 28.4%, p<0.001). The CS rate in RG 5 and RG 10 was different (p<0.01 for both). The most relative frequent RG in both units consisted of group 5, followed by group 10 and 2a. CONCLUSIONS: The analysis allowed us to explain different CS rates with differences in the study population and with differences in the clinical practice. These results serve as a starting point for audits, inter-hospital comparisons and for interventions aiming to reduce CS rates.

Respectful maternal and newborn care: measurement in one EN-BIRTH study hospital in Nepal.

BACKGROUND: Respectful maternal and newborn care (RMNC) is an important component of high-quality care but progress is impeded by critical measurement gaps for women and newborns. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study was an observational study with mixed methods assessing measurement validity for coverage and quality of maternal and newborn indicators. This paper reports results regarding the measurement of respectful care for women and newborns. METHODS: At one EN-BIRTH study site in Pokhara, Nepal, we included additional questions during exit-survey interviews with women about their experiences (July 2017-July 2018). The questionnaire was based on seven mistreatment typologies: Physical; Sexual; or Verbal abuse; Stigma/discrimination; Failure to meet professional standards of care; Poor rapport between women and providers; and Health care denied due to inability to pay. We calculated associations between these typologies and potential determinants of health - ethnicity, age, sex, mode of birth - as possible predictors for reporting poor care. RESULTS: Among 4296 women interviewed, none reported physical, sexual, or verbal abuse. 15.7% of women were dissatisfied with privacy, and 13.0% of women reported their birth experience did not meet their religious and cultural needs. In descriptive analysis, adjusted odds ratios and multivariate analysis showed primiparous women were less likely to report respectful care (ß = 0.23, p-value < 0.0001). Women from Madeshi (a disadvantaged ethnic group) were more likely to report poor care (ß = - 0.34; p-value 0.037) than women identifying as Chettri/Brahmin. Women who had caesarean section were less likely to report poor care during childbirth (ß = - 0.42; p-value < 0.0001) than women with a vaginal birth. However, babies born by caesarean had a 98% decrease in the odds (aOR = 0.02, 95% CI, 0.01-0.05) of receiving skin-to-skin contact than those with vaginal births. CONCLUSIONS: Measurement of respectful care at exit interview after hospital birth is challenging, and women generally reported 100% respectful care for themselves and their baby. Specific questions, with stratification by mode of birth, women's age and ethnicity, are important to identify those mistreated during care and to prioritise action. More research is needed to develop evidence-based measures to track experience of care, including zero separation for the mother-newborn pair, and to improve monitoring.

A Novel Use of Artificial Intelligence to Examine Diversity and Hospital Performance.

BACKGROUND: The US population is becoming more racially and ethnically diverse. Research suggests that cultural diversity within organizations can increase team potency and performance, yet this theory has not been explored in the field of surgery. Furthermore, when surveyed, patients express a desire for their care provider to mirror their own race and ethnicity. In the present study, we hypothesize that there is a positive correlation between a high ranking by the US News and World Report for gastroenterology and gastrointestinal (GI) surgery and greater racial, ethnic, and gender diversity among the physicians and surgeons. METHODS: We used the 2019 US News and World Report rankings for best hospitals by specialty to categorize gastroenterology and GI surgery departments into 2 groups: 1-50 and 51-100. Hospital websites of these top 100 were viewed to determine if racial diversity and inclusion were highlighted in the hospitals' core values or mission statements. To determine the rates of diversity within departments, Betaface (Betaface.com) facial analysis software was used to analyze photos taken from the hospitals' websites. This software was able to determine the race, ethnicity, and gender of the care providers. We examined the racial and ethnic makeup of the populations served by these hospitals to see if the gastroenterologists and surgeons adequately represented the state population. We then ran the independent samples t-test to determine if there was a difference in rankings of more diverse departments. RESULTS: Hospitals with gastroenterology and GI surgery departments in the top 50 were more likely to mention diversity on their websites compared with hospitals that ranked from 51-100 (76% versus 56%; P = 0.035). The top 50 hospitals had a statistically significant higher percentage of underrepresented minority GI physicians and surgeons (7.01% versus 4.04%; P < 0.001). In the 31 states where these hospitals were located, there were more African Americans (13% versus 3%; P < 0.001) and Hispanics (12% versus 2%; P < 0.001), while there were fewer Asians (4% versus 21%; P < 0.001) in the population compared with the faculty. CONCLUSIONS: We used artificial intelligence software to determine the degree of racial and ethnic diversity in gastroenterology and GI surgery departments across the county. Higher ranking hospitals had a greater degree of diversity of their faculty and were more likely to emphasize diversity in their mission statements. Hospitals stress the importance of having a culturally diverse staff, yet their care providers may not adequately reflect the populations they serve. Further work is needed to prospectively track diversity rates over time and correlate these changes with measurable outcomes.

Demographics matter: the potentially disproportionate effect of COVID-19 on hospital ratings.

OBJECTIVE: To identify how features of the community in which a hospital serves differentially relate to its patients' experiences based on the quality of that hospital. DESIGN: A Finite Mixture Model (FMM) is used to uncover a mix of two latent groups of hospitals that differ in quality. In the FMM, a multinomial logistic equation relates hospital-level factors to the odds of being in either group. And a multiple linear regression relates the characteristics of communities served by hospitals to the patients' expected ratings of their experiences at hospitals in each group. Thus, this association potentially varies with hospital quality. The analysis was conducted via Stata. SETTING: Hospital Ratings are measured by Hospital Compare using the HCAHPS survey, a patient satisfaction survey required by the Centers for Medicare and Medicaid Services (CMS) for hospitals in the United States. Participants: 2,816 Medicare-certified acute care hospitals across all US states.

Insurance Status and Disparities in Outpatient Care after Traumatic Injuries of the Hand: A Retrospective Cohort Study.

BACKGROUND: Hand-injured patients seen in the emergency department can often be followed as outpatients for definitive care and rehabilitation. Many face barriers to continuing care in the outpatient setting that impact quality of care delivery. The authors aimed to evaluate patterns of outpatient follow-up after initial emergency department evaluation of traumatic hand injuries, identify factors associated with poor follow-up, and suggest areas for improvement. METHODS: In this retrospective cohort study, the authors reviewed records of adult patients with acute hand injuries referred for outpatient follow-up after initial plastic surgery consultation in the emergency department of a single urban Level I trauma center over a 12-month period (n = 300). Patients were grouped by insurance (i.e., no insurance, Medicaid, Medicare, or private). Outcomes included completion of outpatient follow-up, hand therapy participation, and emergency department return visits. RESULTS: Factors significantly associated with failure to follow up included male sex (OR, 3.58; 95 percent CI, 1.57 to 8.16), uninsured status (OR, 3.47; 95 percent CI, 1.48 to 8.16), Medicaid insurance (OR, 4.46; 95 percent CI, 1.31 to 15.25), and lack of a driver's license (OR, 3.35; 95 percent CI, 1.53 to 7.34). Hand therapy attendance and unexpected emergency department return visits also varied significantly by insurance type (p < 0.001). CONCLUSIONS: There is a significant disparity in the use of outpatient care after emergency department visits for acute hand injuries. Uninsured and Medicaid-insured patients are significantly less likely to initiate recommended hand specialty follow-up, and significantly less likely to complete follow-up even when established with an outpatient clinic. Future research should evaluate targeted interventions for at-risk patients.

Impact of a prolonged COVID-19 lockdown on patterns of admission, mortality and performance indicators in a cardiovascular intensive care unit.

BACKGROUND: The effects of an early and prolonged lockdown during the coronavirus disease 2019 (COVID-19) pandemic on cardiovascular intensive care units (CICUs) are not well established. OBJECTIVES: This study analyses patterns of admission, mortality and performance indicators in a CICU before and during the Argentine lockdown in the COVID-19 pandemic. METHODS: This is a retrospective observational cross-sectional study of all consecutive patients aged 18 years or more admitted to the cardiac intensive care unit at a high-volume reference hospital in Buenos Aires, Argentina, comparing hospitalization rates, primary causes of admission, inpatient utilization indicators, pharmacy supplies' expenditures and in-hospital mortality between 5 March and 31 July 2020, with two corresponding control periods in 2019 and 2018. RESULTS: We included 722 female patients [mean age of 61.6 (SD 15.5) years; 237 (32.8%)]. Overall hospitalizations dropped 53.2% (95%CI: 45.3, 61.0%), from 295.5 patients/year over the periods 2018/2019 to 137 patients in 2020. Cardiovascular disease-related admissions dropped 59.9%, while admission for non-cardiac causes doubled its prevalence from 9.6% over the periods 2018/2019 to 22.6% in the study period (P < 0.001).In the period 2020, the bed occupancy rate fell from 82.2% to 77.4%, and the bed turnover rate dropped 50% from 7.88 to 3.91 monthly discharges/bed. The average length of stay doubled from 3.26 to 6.75 days, and the turnover interval increased from 3.8 to 8.39 days in 2020.Pharmacy supplies' expenditures per discharge increased 134% along with a rise in antibiotics usage from 6.5 to 11.4 vials/ampoules per discharge (P < 0.02).Overall mortality increased from 7% (n = 41) to 13.9% (n = 19) (P = 0.008) at the expense of non-cardiac-related admissions (3.6-19.4%, P = 0.01). CONCLUSIONS: This study found a significant reduction in overall and cardiovascular disease-related causes of admission to the cardiac intensive care unit, worse performance indicators and increased in-hospital mortality along the first 5 months of the early and long-lasting COVID-19 lockdown in Argentina. These results highlight the need to foster public awareness concerning the risks of avoiding hospital attendance. Moreover, health systems should follow strict screening protocols to prevent potential biases in the admission of patients with critical conditions unrelated to the COVID-19 pandemic.

Explaining Racial Disparities in Surgically Treated Head and Neck Cancer.

OBJECTIVES/HYPOTHESIS: To assess the causative factors that contribute to racial disparities in head and neck squamous cell carcinoma (HNSCC) and establish the role of hospital factors in racial disparities. STUDY DESIGN: Retrospective database analysis. METHODS: Patients with surgically treated HNSCC were identified using the National Cancer Database (2004-2014). Logistic and proportional-hazard regression models were used to characterize the factors that contribute to racial disparities. Differences in quality of care received were compared among black and white patients using previously validated metrics. RESULTS: We identified 69,186 eligible patients. Black patients had a 48% higher mortality than white patients (HR 1.48; 95% confidence interval [CI], 1.41-1.54). Black patients had a lower mean quality score (67.6%; 95% CI, 66.8%-69.4%) compared with white patients (71.2%: 95% CI, 71.0%-71.4%) for five quality metrics. After adjusting for differences in patient, oncologic, and hospital factors we were able to explain 60% of the excess mortality for black patients. Oncologic factors at presentation accounted for 57.7% of observed mortality differences, whereas hospital characteristics and quality of care accounted for 11.5%. After adjusting for these factors, black patients still had a 19% higher mortality (HR 1.19; 95% CI, 1.14-1.24). CONCLUSIONS: Oncologic factors at presentation are a major contributor to racial disparities in outcomes for HNSCC. Hospital factors, such as quality, volume, and safety-net status, constitute a minor factor in the mortality difference. Resolving existing disparities will require detecting head and neck cancer at an earlier stage and improving the quality of care for black patients. LEVEL OF EVIDENCE: 3. Laryngoscope, 131:1053-1059, 2021.

Quality indicators for the evaluation of end-of-life care in Germany - a retrospective cross-sectional analysis of statutory health insurance data.

BACKGROUND: The provision and quality of end-of-life care (EoLC) in Germany is inconsistent. Therefore, an evaluation of current EoLC based on quality indicators is needed. This study aims to evaluate EoLC in Germany on the basis of quality indicators pertaining to curative overtreatment, palliative undertreatment and delayed palliative care (PC). Results were compared with previous findings. METHODS: Data from a statutory health insurance provider (AOK Lower Saxony) pertaining to deceased members in the years 2016 and 2017 were used to evaluate EoLC. The main indicators were: chemotherapy for cancer patients in the last month of life, first-time percutaneous endoscopic gastrostomy (PEG) for patients with dementia in the last 3 months of life, number of hospitalisations and days spent in inpatient treatment in the last 6 months of life, and provision of generalist and specialist outpatient PC in the last year of life. Data were analysed descriptively. RESULTS: Data for 64,275 deceased members (54.3% female; 35.1% cancer patients) were analysed. With respect to curative overtreatment, 10.4% of the deceased with cancer underwent chemotherapy in the last month and 0.9% with dementia had a new PEG insertion in the last 3 months of life. The mean number of hospitalisations and inpatient treatment days per deceased member was 1.6 and 16.5, respectively, in the last 6 months of life. Concerning palliative undertreatment, generalist outpatient PC was provided for 28.0% and specialist outpatient PC was provided for 9.0% of the deceased. Regarding indicators for delayed PC, the median onset of generalist and specialist outpatient PC was 47.0 and 24.0 days before death, respectively. CONCLUSION: Compared to data from 2010 to 2014, the data analysed in the present study suggest an ongoing curative overtreatment in terms of chemotherapy and hospitalisation, a reduction in new PEG insertions and an increase in specialist PC. The number of patients receiving generalist PC remained low, with delayed onset. Greater awareness of generalist PC and the early integration of PC are recommended. TRIAL REGISTRATION: The study was registered in the German Clinical Trials Register ( DRKS00015108 ; 22 January 2019).

Prevalence of pressure ulcers among hospitalized adult patients in Ethiopia: a systematic review and meta-analysis.

BACKGROUND: Globally, PUs are recognized as one of the five most frequent causes of harm to clients. With millions affected globally, the national pooled prevalence of pressure ulcers in Ethiopia remains unknown. Hence, this review and meta-analysis aimed to determine the prevalence of pressure ulcers among hospitalized clients in Ethiopia. METHODS: Studies were retrieved through search engines in PubMed, Scopus, WHO Afro Library, Google Scholar, Africa Journals Online, and Web of Science. Heterogeneity between-studies were checked using the I2 test. A funnel plot and Egger's regression test was used to assess the presence of publication bias. The random-effect model was fitted to estimate summary effects and 95% confidence intervals (CIs) across studies. The analyses were performed using STATA™ Version 14 software. RESULTS: The pooled prevalence of pressure ulcer in Ethiopia was assessed using seven studies involving a total of 1881 participants. The pooled prevalence of pressure ulcers in Ethiopia was 11.7% (95% CI: 7.28, 16.13). The subgroup analysis showed that the estimated magnitude of pressure ulcers was 15.89% (95% CI: 13.32, 18.46); among studies, their sample size was greater than or equal to 250. CONCLUSION: The current review reported that the pooled prevalence of pressure ulcers in Ethiopia was relatively high. Hence, policymaker and healthcare providers should give attention to reduce the magnitude of pressure ulcers. Furthermore, further a meta-analysis study could be conducted to identify individual and health care service-related factors related to the occurrence of pressure ulcers.

Primary care quality and cost for privately insured patients in and out of US Health Systems: Evidence from four states.

OBJECTIVE: To characterize physician health system membership in four states between 2012 and 2016 and to compare primary care quality and cost between in-system providers and non-system providers for the commercially insured population. DATA SOURCES: Physician membership in health systems was obtained from a unique longitudinal database on health systems and matched at the provider level to 2014 all-payer claims data from Colorado, Massachusetts, Oregon, and Utah. STUDY DESIGN: Using an observational study design, we compared physicians in health systems to non-system physicians located in the same state and geography on average cost of care (risk-adjusted using the Johns Hopkins' Adjusted Clinical Grouper), five HEDIS quality measures, one measure of developmental screening, and two Prevention Quality Indicator Measures. DATA COLLECTION/EXTRACTION METHODS: Patients in commercial health plans were attributed to a primary care physician accounting for the plurality of office visits. A cohort for each quality measure was constructed based on appropriate measure specifications. PRINCIPAL FINDINGS: The share of physicians in health systems increased steadily from 2012 to 2016 and ranged from 48% in Colorado to 63% in Utah in 2016. Compared to physicians not in a system, system physicians performed similarly on most HEDIS quality metrics compared to non-system physicians. Patients attributed to in-system physicians had about 40% higher rates (P < .05) of Ambulatory Care Sensitive Admissions (measured in admissions per 100 000:921.33 in-system vs 674.61 not-in-system for acute composite; 2540.91 in-system vs 1972.17 for chronic composite In-system providers were associated with $29 (P < .05) higher average per member per month costs (453.37 vs 432.93). Overall, differences in performance by system membership were relatively small compared to differences across states and geography. CONCLUSION: A growing share of physicians is part of a health system from 2012 to 2016. Providers in health systems are not delivering primary care more efficiently than non-system providers for the commercially insured.

Racial and ethnic disparities in care for health system-affiliated physician organizations and non-affiliated physician organizations.

OBJECTIVE: To assess racial and ethnic disparities in care for Medicare fee-for-service (FFS) beneficiaries and whether disparities differ between health system-affiliated physician organizations (POs) and nonaffiliated POs. DATA SOURCES: We used Medicare Data on Provider Practice and Specialty (MD-PPAS), Medicare Provider Enrollment, Chain, and Ownership System (PECOS), IRS Form 990, 100% Medicare FFS claims, and race/ethnicity estimated using the Medicare Bayesian Improved Surname Geocoding 2.0 algorithm. STUDY DESIGN: Using a sample of 16 007 POs providing primary care in 2015, we assessed racial/ethnic disparities on 12 measures derived from claims (2 cancer screenings; diabetic eye examinations; continuity of care; two medication adherence measures; three measures of follow-up visits after acute care; all-cause emergency department (ED) visits, all-cause readmissions, and ambulatory care-sensitive admissions). We decomposed these "total" disparities into within-PO and between-PO components using models with PO random effects. We then pair-matched 1853 of these POs that were affiliated with health systems to similar nonaffiliated POs. We examined differences in within-PO disparities by affiliation status by interacting each nonwhite race/ethnicity with an affiliation indicator. DATA COLLECTION/EXTRACTION METHODS: Medicare Data on Provider Practice and Specialty identified POs billing Medicare; PECOS and IRS Form 990 identified health system affiliations. Beneficiaries age 18 and older were attributed to POs using a plurality visit rule. PRINCIPAL FINDINGS: We observed total disparities in 12 of 36 comparisons between white and nonwhite beneficiaries; nonwhites received worse care in 10. Within-PO disparities exceeded between-PO disparities and were substantively important (>=5 percentage points or>=0.2 standardized differences) in nine of the 12 comparisons. Among these 12, nonaffiliated POs had smaller disparities than affiliated POs in two comparisons (P < .05): 1.6 percentage points smaller black-white disparities in follow-up after ED visits and 0.6 percentage points smaller Hispanic-white disparities in breast cancer screening. CONCLUSIONS: We find no evidence that system-affiliated POs have smaller racial and ethnic disparities than nonaffiliated POs. Where differences existed, disparities were slightly larger in affiliated POs.

Key indicators for appraising adolescent sexual and reproductive health in South Asia: international expert consensus exercise using the Delphi technique.

BACKGROUND: There is a need for an accurate assessment of the patterns and determinants of sexual and reproductive health in South Asia owing to high fertility rates and high incidence of unplanned pregnancy among adolescents. Health indicator sets, with a wide range of health dimensions, also support in formulating evidence-based policies. For attaining this, indicators should be developed and prioritized based on consensus and relevance. OBJECTIVE: This study aimed to develop a comprehensive list of adolescent sexual and reproductive health (ASRH) key indicators for South Asia through systematic participatory expert consultation exercise using the Delphi technique. METHODS: Experts were invited to two rounds of an indicator rating exercise and a third round to discuss the results in a broader regional perspective. A list of nine indicator categories, including 41 adolescent health indicators, was rated by the expert panel. Prioritization was based on mean Likert scores while consensus was established using Kendall's W. RESULTS: 24, 16 and six experts participated in the first, second and third round, respectively. Out of the nine indicator categories, demographics, reproductive health, violence, and nutrition were ranked high in relevance by the expert panel. Experts had a strong consensus on the relevance of parental control and connection, and behavioral indicators while there was moderate consensus on the relevance of nutrition, infectious disease, and mortality indicators. CONCLUSION: As far as we know, this is the first study that employs the Delphi technique for prioritizing ASRH indicators for South Asia. Engaging a diverse group of experts, using an online platform, we developed a comprehensive list of key indicators for appraising ASRH relevant to South Asia based on expert panel consensus and recommendations. Our results also highlight that there is a need for developing a region-specific prioritized list of indicators which might assist in identifying regional health needs.

Family and Friend Perceptions of Quality of End-of-Life Care in Medicare Advantage vs Traditional Medicare.

Importance: Medicare Advantage (MA) insures an increasing proportion of Medicare beneficiaries, but evidence is lacking on patient or family perceptions of the quality of end-of-life care in MA vs traditional Medicare. Objective: To determine if there is a difference in quality of care reported by family and friends of individuals who died while insured by MA vs traditional Medicare at the end of life. Design, Setting, and Participants: This cross-sectional study used the 2011 to 2017 Medicare-linked National Health and Aging Trends Study to conduct population-based survey research representing 8 668 829 Medicare enrollees. Included individuals were 2119 enrollees who died when aged 65 years or older, with quality of care reported by a family member or close friend familiar with the individual's last month of life. Analysis was conducted in July 2020. Exposures: MA enrollment at the time of death or before hospice enrollment. Main Outcomes and Measures: Perception of end-of-life care was measured with 9 validated items, with the primary outcome variable being overall care rated not excellent. We conducted a propensity score-weighted multivariable model to examine the association of each item with MA vs traditional Medicare enrollment. The propensity score and multivariable model included covariates capturing demographic and socioeconomic factors, function and health, and relationship of the respondent to the individual who died. The sample was then stratified by hospice enrollment and setting of care in the last month. Results: Of 2119 people in the sample, 670 individuals were enrolled in MA at the time of death or prior to hospice (32.7%) and 1449 were enrolled in traditional Medicare (67.3%). In survey-weighted percentages, 53.6% (95% CI, 51.0% to 56.1%) were women and 43.4% (95% CI, 41.5% to 45.3%) were older than 85 years at the time of death. In the adjusted model, family and friends of individuals in MA were more likely to report that care was not excellent (odds ratio, 1.28; 95% CI, 1.01 to 1.61; P = .04) and that they were not kept informed (odds ratio, 1.48; 95% CI, 1.06 to 2.05; P = .02). For those in nursing homes, there was an estimated probability of 57.2% of respondents reporting that care was not excellent for individuals with traditional Medicare, compared with 77.9% of respondents for individuals with MA (marginal increase for those in MA, 0.21; 95% CI, 0.08 to 0.32; P = .001). Conclusions and Relevance: In this cross-sectional study of people who died while enrolled in Medicare, friends and family of those in MA reported lower-quality end-of-life care compared with friends and family of those enrolled in traditional Medicare. These findings suggest that, given the rapid growth of MA, Medicare should take steps to ensure that MA plans are held accountable for quality of care at the end of life.