Photobiomodulation for the prevention and treatment of oral mucositis in patients submitted to hematopoietic stem cell transplantation: health quality evaluation.

OBJECTIVE: To evaluate the quality of oral health care through indicators in patients undergoing hematopoietic stem cell transplantation for the management of oral mucositis. METHODS: Thirty-five patients were evaluated. Photobiomodulation was performed during the conditioning regimen, 1 day, 5 days, and 10 days after transplantation. Four process indicators and 13 outcome indicators were used to evaluate the effectiveness of the intervention, according to SQUIRE 2.0. RESULTS: All process indicators demonstrated a compliance rate of 100% to the desired standard. Outcome indicators revealed that 66.6% of patients experienced mucositis during at least one follow-up period. A statistically significant increase was observed between periods of 1 and 5 days post-transplant, as well as between 1 and 10 days post-transplant (p < 0.05), with a predominance of grade I mucositis (p = 0.014). Four patients (16.7%) reported feeling pain, occurring between 5 and 10 days after transplantation, with moderate pain being the most prevalent. Oral mucositis did not show a statistically significant association with pain, associated treatments, leukopenia, comorbidities, or type of transplant. CONCLUSIONS: The indicators demonstrated their suitability for evaluating oral health in both the prevention and treatment of oral mucositis in these patients. Furthermore, the effectiveness of photobiomodulation in improving the quality of oral health in the patients studied was confirmed.

Incidence of complications after nonoperating room anesthesia in children in a low- and middle-income country: A prospective and observational study.

INTRODUCTION: Nonoperating room anesthesia is a growing field of medicine that can have an increased risk of complications, particularly in low- and middle-income countries. AIMS: The aim of this study was to describe the incidence of complications after pediatric nonoperating room anesthesia and investigate its risk factors. METHODS: In this prospective observational study, we included all children aged less than 5 years who were sedated or anesthetized in the radiology setting of a university hospital in a low- and middle-income country. Patients were divided into two groups: complications or no-complications groups. Then, we compared both groups, and univariable and multivariable logistic regression models were used to investigate the main risk factors for complications. RESULTS: We included 256 children, and the incidence of complications was 8.6%. The main predictors of nonoperating room anesthesia-related morbidity were: critically-ill children (aOR = 2.490; 95% CI: 1.55-11.21), predicted difficult airway (aOR = 5.704; 95% CI: 1.017-31.98), and organization insufficiencies (aOR = 52.6; 95% CI:4.55-613). The preanesthetic consultation few days before NORA protected against complications (aOR = 0.263; 95%CI: 0.080-0.867). CONCLUSIONS: The incidence of complications during NORA among children in our radiology setting remains high. Investigating predictors for morbidity allowed high-risk patient selection, which allowed taking precautions. Several improvement measures were taken to address the organization's insufficiencies.

Quality appraisal of clinical nutrition practice guidelines for critically ill adult patients: a systematic review using the Advancing Guideline Development, Reporting and Evaluation in Health Care instrument II (AGREE-II) and AGREE-Recommendation Excellence (AGREE-REX).

Nutritional therapy should follow evidence-based practice, thus several societies regarding nutrition and critical care have developed specific Clinical Practice Guidelines (CPG). However, to be regarded as trustworthy, the quality of the CPG for critically ill patients and its recommendations need to be high. This systematic review aimed to appraise the methodology and recommendations of nutrition CPG for critically ill patients. We performed a systematic review (protocol number CRD42020184199) with literature search conducted on PubMed, Embase, Cochrane Library and other four specific databases of guidelines up to October 2021. Two reviewers, independently, assessed titles and abstracts and potentially eligible full-text reports to determine eligibility and subsequently four reviewers appraised the guidelines quality using the Advancing Guideline Development, Reporting and Evaluation in Health Care instrument II (AGREE-II) and AGREE-Recommendation Excellence (AGREE-REX). Ten CPG for nutrition in critically ill patients were identified. Only Academy of Nutrition and Dietetics and European Society of Intensive Care Medicine had a total acceptable quality and were recommended for daily practice according AGREE-II. None of the CPG recommendations had an overall quality score above 70 %, thus being classified as moderate quality according AGREE-REX. The methodological evaluation of the critically ill adult patient CPG revealed significant discrepancies and showed a need for improvement in its development and/or reporting. In addition, recommendations about nutrition care process presented a moderate quality.

Clinicians' perceptions and practices of diagnostic assessment in psychiatric services.

BACKGROUND: Diagnostic assessment in psychiatric services typically involves applying clinical judgment to information collected from patients using multiple sources, including anamnesis and structured diagnostic interviews. Research shows that clinicians' perceptions of diagnostic assessment are associated with their diagnostic practices, and that perceptions and practices may vary according to clinician characteristics. Examining clinicians' perceptions and practices of diagnostic assessment is important for quality improvement in psychiatric services, including implementation of evidence-based practice procedures. The purpose of the present study was to evaluate clinicians' perceptions and practices of diagnostic assessment in psychiatric services and examine whether these perceptions and practices varied according to profession and age, with the aim of providing a basis for quality improvement. METHODS: A total of 183 (53.2%) clinicians in community-based adult psychiatric services in Stockholm, Sweden participated in an online survey. Differences between professions were analyzed using Kruskal-Wallis tests and effect sizes were calculated. Associations of clinicians' perceptions with their age were examined using Spearman correlations. RESULTS: Overall, clinicians had positive attitudes toward diagnostic assessment, and they considered themselves as competent. Differences were as most pronounced between nurses and other professions. Nursed had conducted fewer assessments, perceived themselves as less competent, and reported to a smaller extent to be able to determine which diagnosis should be the target for treatment in patients with multiple diagnoses. There were no associations of clinicians' perceptions with their age. Some potential areas of improvement were identified, including clinician qualifications, education in diagnostic assessment, and contents of diagnostic assessment. CONCLUSIONS: The results of the present study may provide a basis for quality improvement in psychiatric services. For example, it may be important to pay attention to potential differences in perceptions and practices between professions in efforts to improve quality of assessment and care.

Evaluation of dialysis centres: values and criteria of the stakeholders.

BACKGROUND: Evaluation of renal replacement therapy with haemodialysis is essential for its improvement. Remarkably, outcomes vary across centres. In addition, the methods used have important epistemological limitations, such as ignoring significant features (e.g., quality of life) or no relevance given to the patient's perspective in the indicator's selection. The present study aimed to determine the opinions and preferences of stakeholders (patients, clinicians, and managers) and establish their relative importance, considering the complexity of their interactions, to facilitate a comprehensive evaluation of haemodialysis centres. METHODS: Successive working groups (WGs) were established using a multicriteria methodology. WG1 created a draft of criteria and sub-criteria, WG2 agreed, using a qualitative structured analysis with pre-established criteria, and WG3 was composed of three face-to-face subgroups (WG3-A, WG3-B, and WG3-C) that weighted them using two methodologies: weighted sum (WS) and analytic hierarchy process (AHP). Subsequently, they determined a preference for the WS or AHP results. Finally, via the Internet, WG4 weighted the criteria and sub-criteria by the method preferred by WG3, and WG5 analysed the results. RESULTS: WG1 and WG2 identified and agreed on the following evaluation criteria: evidence-based variables (EBVs), annual morbidity, annual mortality, patient-reported outcome measures (PROMs), and patient-reported experience measures (PREMs). The EBVs consisted of five sub-criteria: type of vascular access, dialysis dose, haemoglobin concentration, ratio of catheter bacteraemia, and bone mineral disease. The patients rated the PROMs with greater weight than the other stakeholders in both face-to-face WG3 (WS and AHP) and WG4 via the Internet. The type of vascular access was the most valued sub-criterion. A performance matrix of each criterion and sub-criterion is presented as a reference for assessing the results based on the preferences of the stakeholders. CONCLUSIONS: The use of a multicriteria methodology allows the relative importance of the indicators to be determined, reflecting the values of the different stakeholders. In a performance matrix, the inclusion of values and intangible aspects in the evaluation could help in making clinical and organizational decisions.

Assessing the performance of indicators during their life cycle: the mixed QUID method.

BACKGROUND: Quality indicators (QI) are mandatory in French hospitals. After a decade of use, the Ministry of Health set up an expert workgroup to enhance informed decision-making regarding currently used national QI, i.e. to propose a decision of withdrawing, revising or continuing their use. We report the development of an integrated method for a comprehensive appraisal of quality/safety indicators (QI) during their life cycle, for three purposes, quality improvement, public disclosure and regulation purposes. The method was tested on 10 national QI on use for up to 10 years to identify operational issues. METHODS: A modified Delphi technique to select relevant criteria and a development of a mixed evaluation method by the workgroup. A 'real-life' test on 10 national QI. RESULTS: Twelve criteria were selected for the appraisal of QI used for regulation goals, 11 were selected for hospital improvement and seven for public disclosure. The perceived feasibility and relevance were studied including hospital workers, patients and health authorities professionals; the scientific soundness of the indicator development phase was reviewed by analyzing reference documents; the metrological performance (limited to the discriminatory power and dynamics of change during the life cycle dimensions) was analyzed on the national datasets.Applied to the 10 QI, the workgroup proposed to withdraw four of them and to modify or suspend the six others. CONCLUSIONS: The value of the method was supported by the clear-cut conclusions and endorsement of the proposed decisions by the health authorities.

Content, Quality, and Assessment Tools of Physician-Rating Websites in 12 Countries: Quantitative Analysis.

BACKGROUND: Websites on which users can rate their physician are becoming increasingly popular, but little is known about the website quality, the information content, and the tools they offer users to assess physicians. This study assesses these aspects on physician-rating websites in German- and English-speaking countries. OBJECTIVE: The objective of this study was to collect information on websites with a physician rating or review tool in 12 countries in terms of metadata, website quality (transparency, privacy and freedom of speech of physicians and patients, check mechanisms for appropriateness and accuracy of reviews, and ease of page navigation), professional information about the physician, rating scales and tools, as well as traffic rank. METHODS: A systematic Web search based on a set of predefined keywords was conducted on Google, Bing, and Yahoo in August 2016. A final sample of 143 physician-rating websites was analyzed and coded for metadata, quality, information content, and the physician-rating tools. RESULTS: The majority of websites were registered in the United States (40/143) or Germany (25/143). The vast majority were commercially owned (120/143, 83.9%), and 69.9% (100/143) displayed some form of physician advertisement. Overall, information content (mean 9.95/25) as well as quality were low (mean 18.67/47). Websites registered in the United Kingdom obtained the highest quality scores (mean 26.50/47), followed by Australian websites (mean 21.50/47). In terms of rating tools, physician-rating websites were most frequently asking users to score overall performance, punctuality, or wait time in practice. CONCLUSIONS: This study evidences that websites that provide physician rating should improve and communicate their quality standards, especially in terms of physician and user protection, as well as transparency. In addition, given that quality standards on physician-rating websites are low overall, the development of transparent guidelines is required. Furthermore, attention should be paid to the financial goals that the majority of physician-rating websites, especially the ones that are commercially owned, pursue.

Variation in the use of advanced imaging at the time of breast cancer diagnosis in a statewide registry.

BACKGROUND: Although national guidelines do not recommend extent of disease imaging for patients with newly diagnosed early stage breast cancer given that the harm outweighs the benefits, high rates of testing have been documented. The 2012 Choosing Wisely guidelines specifically addressed this issue. We examined the change over time in imaging use across a statewide collaborative, as well as the reasons for performing imaging and the impact on cost of care. METHODS: Clinicopathologic data and use of advanced imaging tests (positron emission tomography, computed tomography, and bone scan) were abstracted from the medical records of patients treated at 25 participating sites in the Michigan Breast Oncology Quality Initiative (MiBOQI). For patients diagnosed in 2014 and 2015, reasons for testing were abstracted from the medical record. RESULTS: Of the 34,078 patients diagnosed with stage 0-II breast cancer between 2008 and 2015 in MiBOQI, 6853 (20.1%) underwent testing with at least 1 imaging modality in the 90 days after diagnosis. There was considerable variability in rates of testing across the 25 sites for all stages of disease. Between 2008 and 2015, testing decreased over time for patients with stage 0-IIA disease (all P < .001) and remained stable for stage IIB disease (P = .10). This decrease in testing over time resulted in a cost savings, especially for patients with stage I disease. CONCLUSION: Use of advanced imaging at the time of diagnosis decreased over time in a large statewide collaborative. Additional interventions are warranted to further reduce rates of unnecessary imaging to improve quality of care for patients with breast cancer. Cancer 2017;123:2975-83. © 2017 American Cancer Society.

Pay for performance associated with increased volume of medication reviews but not with less inappropriate use of medications among the elderly - an observational study.

OBJECTIVE: A pay for performance programme was introduced in 2009 by a Swedish county with 1.6 million inhabitants. A process measure with payment linked to coding for medication reviews among the elderly was adopted. We assessed the association with inappropriate medication for five years after baseline. DESIGN AND SETTING: Observational study that compared medication for elderly patients enrolled at primary care units that coded for a high or low volume of medication reviews. PATIENTS: 144,222 individuals at 196 primary care centres, age 75 or older. MAIN OUTCOME MEASURES: Percentage of patients receiving inappropriate drugs or polypharmacy during five years at primary care units with various levels of reported medication reviews. RESULTS: The proportion of patients with a registered medication review had increased from 3.2% to 44.1% after five years. The high-coding units performed better for most indicators but had already done so at baseline. Primary care units with the lowest payment for coding for medication reviews improved just as well in terms of inappropriate drugs as units with the highest payment - from 13.0 to 8.5%, compared to 11.6 to 7.4% and from 13.6 to 7.2% vs 11.8 to 6.5% for polypharmacy. CONCLUSIONS: Payment linked to coding for medication reviews was associated with an increase in the percentage of patients for whom a medication review had been registered. However, the impact of payment on quality improvement is uncertain, given that units with the lowest payment for medication reviews improved equally well as units with the highest payment.

New Mandated Centers for Medicare and Medicaid Services Requirements for Sepsis Reporting: Caution from the Field.

BACKGROUND: The release of the Center for Medicare and Medicaid Service's (CMS) latest quality measure, Severe Sepsis/Septic Shock Early Management Bundle (SEP-1), has intensified the long-standing debate over optimal care for severe sepsis and septic shock. Although the last decade of research has demonstrated the importance of comprehensive bundled care in conjunction with compliance mechanisms to reduce patient mortality, it is not clear that SEP-1 achieves this aim. The heterogeneous and often cryptic presentation of severe sepsis and septic shock, along with the multifaceted criteria for the definition of this clinical syndrome, pose a particular challenge for fitting requirements to this disease, and implementation could have unintended consequences. OBJECTIVE: Following a simulated reporting exercise, in which 50 charts underwent expert review, we aimed to detail the challenges of, and offer suggestions on how to rethink, measuring performance in severe sepsis and septic shock care. DISCUSSION: There were several challenges associated with the design and implementation of this measure. The ambiguous definition of severe sepsis and septic shock, prescriptive fluid volume requirements, rigid reassessment, and complex abstraction logic all raise significant concern. CONCLUSIONS: Although SEP-1 represents an important first step in requiring hospitals to improve outcomes for patients with severe sepsis and septic shock, the current approach must be revisited. The volume and complexity of the currently required SEP-1 reporting elements deserve serious consideration and revision before they are used as measures of accountability and tied to reimbursement.

Consumer Decision-Making Based on Review Websites: Are There Differences Between Choosing a Hotel and Choosing a Physician?

BACKGROUND: Web users are increasingly encouraged to rate and review consumer services (eg, hotels, restaurants) and, more recently, this is also the case for physicians and medical services. The resemblance in the setup and design of commercial rating websites (CRWs) and Web-based physician rating websites (PRWs) raises the question of whether choice-making processes based on the two types of websites could also be similar. OBJECTIVE: This qualitative study sought to explore the extent to which consumer decision making based on Web-based reviews is the same for consumer services (ie, choice of a hotel) and health services (ie, choice of a pediatrician), while providing an in-depth understanding of potential differences or similarities. METHODS: Between June and August 2015, we carried out a total of 22 qualitative interviews with young parents residing in the German-speaking part of Switzerland. Participants were invited to complete 2 choice tasks, which involved (1) choosing a hotel based on the commercial Web-based rating website TripAdvisor and (2) selecting a pediatrician based on the PRW Jameda. To better understand consumers' thought processes, we instructed participants to "think aloud", namely to verbalize their thinking while sorting through information and reaching decisions. Using a semistructured interview guide, we subsequently posed open-ended questions to allow them to elaborate more on factors influencing their decision making, level of confidence in their final choice, and perceived differences and similarities in their search for a hotel and a physician. All interviews were recorded, transcribed, and analyzed using an inductive thematic approach. RESULTS: Participants spent on average 9:57 minutes (standard deviation=9:22, minimum=3:46, maximum=22:25) searching for a hotel and 6:17 minutes (standard deviation=4:47, minimum=00:38, maximum=19:25) searching for a pediatrician. Although the choice of a pediatrician was perceived as more important than the choice of a hotel, participants found choosing a physician much easier than selecting an appropriate accommodation. Four main themes emerged from the analysis of our interview data that can explain the differences in search time and choice confidence: (1) trial and error, (2) trust, (3) competence assessment, and (4) affect and likeability. CONCLUSIONS: Our results suggest that, despite congruent website designs, individuals only trust review information to choose a hotel, but refuse to fully rely on it for selecting a physician. The design and content of Web-based PRWs need to be adjusted to better address the differing information needs of health consumers.

Identification of performance indicators across a network of clinical cancer programs.

BACKGROUND: Cancer quality indicators have previously been described for a single tumour site or a single treatment modality, or according to distinct data sources. Our objective was to identify cancer quality indicators across all treatment modalities specific to breast, prostate, colorectal, and lung cancer. METHODS: Candidate indicators for each tumour site were extracted from the relevant literature and rated in a modified Delphi approach by multidisciplinary groups of expert clinicians from 3 clinical cancer programs. All rating rounds were conducted by e-mail, except for one that was conducted as a face-to-face expert panel meeting, thus modifying the original Delphi technique. Four high-level indicators were chosen for immediate data collection. A list of confounding variables was also constructed in a separate literature review. RESULTS: A total of 156 candidate indicators were identified for breast cancer, 68 for colorectal cancer, 40 for lung cancer, and 43 for prostate cancer. Iterative rounds of ratings led to a final list of 20 evidence- and consensus-based indicators each for colorectal and lung cancer, and 19 each for breast and prostate cancer. Approximately 30 clinicians participated in the selection of the breast, lung, and prostate indicators; approximately 50 clinicians participated in the selection of the colorectal indicators. CONCLUSIONS: The modified Delphi approach that incorporates an in-person meeting of expert clinicians is an effective and efficient method for performance indicator selection and offers the added benefit of optimal clinician engagement. The finalized indicator lists for each tumour site, together with salient confounding variables, can be directly adopted (or adapted) for deployment within a performance improvement program.

Raising the quality of rheumatology management recommendations: lessons from the EULAR process 10 years after provision of standard operating procedures.

OBJECTIVE: To increase understanding of how to raise the quality of rheumatology guidelines by reviewing European League Against Rheumatism (EULAR) management recommendations, using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, 10 years after publication of the EULAR standardized operating procedures (SOP) for the production of recommendations. It was hoped that this work could help inform improvements in guideline development by other societies and organizations. METHODS: The SOP were published in 2004 to ensure the quality of EULAR-endorsed recommendations. We reviewed 27 published EULAR recommendations for management using the AGREE II tool. This provides a framework to assess the quality of guidelines across six broad domains using 23 specific questions. RESULTS: Overall the EULAR recommendations reviewed have been performed to a high standard. There are particular strengths in the methodology and presentation of the guidelines; however, the results indicate areas for development in future recommendations: in particular, stakeholder involvement and applicability of the recommendations. Improvements in quality were evident in recent years, with patient representation in 9 of 15 (60.0%) recommendations published 2010-14 compared with 4 of 12 (33.3%) published 2000-09. CONCLUSION: In the last 10 years the overall quality of recommendations was good, with standards improving over the decade following publication of the SOP. However, this review process has identified potential areas for improvement, especially in patient representation and provision of implementation tools. The lessons from this work can be applied to the development of rheumatology guidelines by other societies and organizations.

Association between drug-specific indicators of prescribing quality and quality of drug treatment: a validation study.

PURPOSE: To evaluate the concurrent validity of three European sets of drug-specific indicators of prescribing quality METHODS: In 200 hip fracture patients (≥65 years), consecutively recruited to a randomized controlled study in Sahlgrenska University Hospital in 2009, quality of drug treatment at study entry was assessed according to a gold standard as well as to three drug-specific indicator sets (Swedish National Board of Health and Welfare, French consensus panel list, and German PRISCUS list). As gold standard, two specialist physicians independently assessed and then agreed on the quality for each patient, after initial screening with STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) and START (Screening Tool to Alert to Right Treatment). RESULTS: According to the Swedish, French, and German indicator sets, 82 (41%), 54 (27%), and 43 (22%) patients had potentially inappropriate drug treatment. A total of 141 (71%) patients had suboptimal drug treatment according to the gold standard. The sensitivity for the indicator sets was 0.51 (95% confidence interval: 0.43; 0.59), 0.33 (0.26; 0.41), and 0.29 (0.22; 0.37), respectively. The specificity was 0.83 (0.72; 0.91), 0.88 (0.77; 0.94), and 0.97 (0.88; 0.99). Suboptimal drug treatment was 2.0 (0.8; 5.3), 1.9 (0.7; 5.1), and 6.1 (1.3; 28.6) times as common in patients with potentially inappropriate drug treatment according to the indicator sets, after adjustments for age, sex, cognition, residence, multi-dose drug dispensing, and number of drugs. CONCLUSIONS: In this setting, the indicator sets had high specificity and low sensitivity. This needs to be considered upon use and interpretation.

Agreement between patients and general practitioners on quality deviations during the cancer diagnostic pathway and associations with time to diagnosis.

BACKGROUND: High quality and minimal delay are crucial and anticipated elements in the diagnostic cancer pathway as delay in the diagnosis may worsen the prognosis and cause lower patient satisfaction. OBJECTIVE: The aim of this study was to describe agreement in reported quality deviations (QDs) between general practitioners (GPs) and cancer patients during the diagnostic pathway in primary care and to estimate the association between length of diagnostic interval and level of agreement on reported QDs. METHODS: The study was carried out as a Danish cross-sectional study of incident cancer patients identified in the Danish National Patient Registry. Data were collected by independent questionnaires from patients (response rate: 53.0%) and their GPs (response rate: 73.8%), and 2177 pairs of questionnaires were subsequently combined. Agreement between GP- and patient-reported QDs was estimated using Cohen's Kappa, whereas the association between level of agreement and time to diagnosis was estimated using quantile regression. RESULTS: Patients reported QDs in 29.0% and GPs in 28.5% of the cases, but agreed only slightly on QD presence (Kappas between -0.08 and 0.26). Agreement on 'QD presence' was associated with a 54-day (95%CI: 44-64) longer time to diagnosis than agreement on 'no QD presence'. The association with a longer diagnostic interval was stronger when only GP reported a QD the association than when only patient reported a QD. CONCLUSION: Included GPs and patients agreed only slightly on QD presence although they reported the same amount of QDs; this suggests that GPs and patients see QDs as two different concepts. QD presence had a stronger impact on time to diagnosis when reported by the GP (alone or in agreement with the patient) than when reported by the patient alone. The GP may thus be the most important source of information on QD and diagnostic interval, while the patient information tends to underpin this assessment.

Short-term effects of a pay-for-performance programme for diabetes in a primary care setting: an observational study.

OBJECTIVE: A pay-for-performance (P4P) programme for primary care was introduced in 2011 by a Swedish county (with 1.6 million inhabitants). Effects on register entry practice and comparability of data for patients with diabetes mellitus were assessed. DESIGN AND SETTING: Observational study analysing short-term outcomes before and after introduction of a P4P programme in the study county as compared with a reference county. SUBJECTS: A total of 84 053 patients reported to the National Diabetes Register by 349 primary care units. MAIN OUTCOME MEASURES: Completeness of data, level and target achievement of glycated haemoglobin (HbA1c), blood pressure (BP), and LDL cholesterol (LDL). RESULTS: In the study county, newly recruited patients who were entered during the incentive programme were less well controlled than existing patients in the register - they had higher HbA1c (54.9 [54.5-55.4] vs. 53.7 [53.6-53.9] mmol/mol), BP, and LDL. The percentage of patients with entry of BP, HbA1c, LDL, albuminuria, and smoking increased in the study county but not in the reference county (+26.3% vs -1.5%). In the study county, with an incentive for BP < 130/80 mmHg, BP data entry behaviour was altered with an increased preference for sub-target BP values and a decline in zero end-digit readings (38.3% vs. 33.7%, p < 0.001). CONCLUSION: P4P led to increased register entry, increased completeness of data, and altered BP entry behaviour. Analysis of newly added patients and data shows that missing patients and data can cause performance to be overestimated. Potential effects on reporting quality should be considered when designing payment programmes. Key points A pay-for-performance programme, with a focus on data entry, was introduced in a primary care region in Sweden. Register data entry in the National Diabetes Register increased and registration behaviour was altered, especially for blood pressure. Newly entered patients and data during the incentive programme were less well controlled. Missing data in a quality register can cause performance to be overestimated.

The effect of certification and accreditation on quality management in 4 clinical services in 73 European hospitals.

OBJECTIVE: To investigate the relationship between ISO 9001 certification, healthcare accreditation and quality management in European hospitals. DESIGN: A mixed method multi-level cross-sectional design in seven countries. External teams assessed clinical services on the use of quality management systems, illustrated by four clinical pathways. SETTING AND PARTICIPANTS: Seventy-three acute care hospitals with a total of 291 services managing acute myocardial infarction (AMI), hip fracture, stroke and obstetric deliveries, in Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey. MAIN OUTCOME MEASURE: Four composite measures of quality and safety [specialized expertise and responsibility (SER), evidence-based organization of pathways (EBOP), patient safety strategies (PSS) and clinical review (CR)] applied to four pathways. RESULTS: Accreditation in isolation showed benefits in AMI and stroke more than in deliveries and hip fracture; the greatest significant association was with CR in stroke. Certification in isolation showed little benefit in AMI but had more positive association with the other conditions; greatest significant association was in PSS with stroke. The combination of accreditation and certification showed least benefit in EBOP, but significant benefits in SER (AMI), in PSS (AMI, hip fracture and stroke) and in CR (AMI and stroke). CONCLUSIONS: Accreditation and certification are positively associated with clinical leadership, systems for patient safety and clinical review, but not with clinical practice. Both systems promote structures and processes, which support patient safety and clinical organization but have limited effect on the delivery of evidence-based patient care. Further analysis of DUQuE data will explore the association of certification and accreditation with clinical outcomes.

Generalizable Approach to Quantifying Guideline-Directed Medical Therapy.

BACKGROUND: Quantifying guideline-directed medical therapy (GDMT) intensity is foundational for improving heart failure (HF) care. Existing measures discount dose intensity or use inconsistent weighting. METHODS: The Kansas City Medical Optimization (KCMO) score is the average of total daily to target dose percentages for eligible GDMT, reflecting the percentage of optimal GDMT prescribed (range, 0-100). In Change the Management of Patients With HF, we computed KCMO, HF collaboratory (0-7), and modified HF Collaboratory (0-100) scores for each patient at baseline and for 1-year change in established GDMT at the time (mineralocorticoid receptor antagonist, ß-blocker, ACE [angiotensin-converting enzyme] inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor). We compared baseline and 1-year change distributions and the coefficient of variation (SD/mean) across scores. RESULTS: Among 4532 patients at baseline, mean KCMO, HF collaboratory, and modified HF Collaboratory scores were 38.8 (SD, 25.7), 3.4 (1.7), and 42.2 (22.2), respectively. The mean 1-year change (n=4061) for KCMO was -1.94 (17.8); HF collaborator, -0.11 (1.32); and modified HF Collaboratory, -1.35 (19.8). KCMO had the highest coefficient of variation (0.66), indicating greater variability around the mean than the HF collaboratory (0.49) and modified HF Collaboratory (0.53) scores, reflecting higher resolution of the variability in GDMT intensity across patients. CONCLUSIONS: KCMO measures GDMT intensity by incorporating dosing and treatment eligibility, provides more granularity than existing methods, is easily interpretable (percentage of ideal GDMT), and can be adapted as performance measures evolve. Further study of its association with outcomes and its usefulness for quality assessment and improvement is needed.

[Synthetic indicator of compliance with standards for Quality Units of health centers and multicenter prospective pilot study]. / Indicador sintético de cumplimiento de estándares para Unidades de Calidad de centros sanitarios y estudio de pilotaje prospectivo multicéntrico.

BACKGROUND AND OBJECTIVE: In Spain, Quality Units play a key and unique role in advising healthcare centers on the methodology of healthcare quality. The objectives of the study were to develop computer algorithms to obtain a synthetic indicator of standard compliance for Quality Units and to pilot its functioning in these units. MATERIALS AND METHODS: The Excel program was used to establish evaluation algorithms, and quantitatively interrelate and weight various categories of standards, as a computer evaluation tool, to build a continuous improvement cycle system, and offer a global synthetic indicator of compliance. The tool was tested in a prospective multicenter pilot study, in which coordinators of Quality Units from different health centers and care settings participated, to evaluate the usefulness of the tool and compliance with the standards, in addition to analyzing the content validity of each standard. RESULTS: The formulas for the structured computer algorithms were developed, consecutively, in a «PLAN-DO-CHECK-ACT¼ improvement cycle for the 9 categories of standards, resulting in a single synthetic indicator of compliance. Twenty-one Quality Units participated in the piloting. The overall average compliance rate for the synthetic indicator was 55.63% with differences between centers (P=.002) and between categories (P<.0001), but not by autonomous communities (P=.86) or by areas (P=.97). Content validity was ensured through the variable of «understanding¼ of the standards (P<.001), and through their «justification¼ with documentary evidence (P<.001). CONCLUSIONS: The computer tool with the synthetic indicator have allowed for the evaluation of standard compliance in Quality Units of healthcare centers.

Effects of patient-centered medical home attributes on patients' perceptions of quality in federally supported health centers.

PURPOSE: We sought to assess patients' ratings of patient-centered medical home (PCMH) attributes and overall quality of care within federally supported health centers. METHODS: Data were collected through the 2009 Health Center Patient Survey (n = 4,562), which consisted of in-person interviews and included a nationally representative sample of patients seen in health centers. Quality measures included patients' perceptions of overall quality of services, perceptions of quality of clinician advice/treatment, and likelihood of referring friends and relatives to the health center. PCMH attributes included (1) access to care getting to health center, (2) access to care during visit, (3) patient-centered communication with health care clinicians, (4) patient-centered communication with support staff, (5) self-management support for chronic conditions, (6) self-management support for behavioral risks, and (7) comprehensive preventive care. Bivariate analysis and logistic regressions were used to examine associations between patients' perceptions of PCMH attributes and patient-reported quality of care. RESULTS: Eighty-four percent of patients reported excellent/very good overall quality of services, 81% reported excellent/very good quality of clinician care, and 84% were very likely to refer friends and relatives. Higher patient ratings on the access to care and patient-centered communication attributes were associated with higher odds of patient-reported high quality of care on the 3 outcome measures. CONCLUSIONS: More than 80% of patients perceived high quality of care in health centers. PCMH attributes related to access to care and communication were associated with greater likelihood of patients reporting high-quality care.