Nutrition Care Process Quality Evaluation and Standardization Tool: The Next Frontier in Quality Evaluation of Documentation.

Documentation is essential for communicating care between credentialed nutrition and dietetics practitioners and other health care providers. A validated tool that can evaluate quality documentation of the Nutrition Care Process (NCP) encounter, including progress on outcomes is lacking. The aim of the NCP Quality Evaluation and Standardization Tool (QUEST) validation study is to revise an existing NCP audit tool and evaluate it when used within US Veterans Affairs in all clinical care settings. Six registered dietitian nutritionists revised an existing NCP audit tool. The revised tool (NCP-QUEST) was analyzed for clarity, relevance, and reliability. Eighty-five documentation notes (44 initial, 41 reassessment) were received from eight volunteer Veterans Affairs sites. Five of six registered dietitian nutritionists participated in the interrater reliability testing blinded to each other's ratings; and two registered dietitian nutritionists participated in intrarater reliability reviewing the same notes 6 weeks later blinded to the original ratings. Results showed moderate levels of agreement in interrater reliability (Krippendorff's α = .62 for all items, .66 for total score, and .52 for quality category rating). Intrarater reliability was excellent for all items (α = .86 to .87 for all items; .91 to .94 for total score and.74 to .89 for quality category rating). The NCP-QUEST has high content validity (Content Validity Index = 0.78 for item level, and 0.9 for scale level) after two cycles of content validity review. The tool can facilitate critical thinking, improved linking of NCP chains, and is a necessary foundation for quality data collection and outcomes management. The NCP-QUEST tool can improve accuracy and confidence in charting.

Integrated care pathways on dementia in Italy: a survey testing the compliance with a national guidance.

Dementias are chronic, degenerative neurological disorders with a complex management that require the cooperation of different healthcare professionals. The Italian Ministry of Health produced the document "Guidance on Integrated Care pathway for People with Dementia" (GICPD) with the specific objective of providing a standardized framework for the definition, development, and implementation of integrated care pathways (ICP) dedicated to people with dementia. We searched all available Italian territorial ICPs. Two raters assessed the retrieved ICPs with a 2-point scale on a 43-item checklist based on the GICPD. Only 5 out of 21 regions and 5 out of 101 local health authorities had an ICP, with most ICPs having a moderate compliance to the GICPD, in particular for the items referring to the development and implementation of the care pathways. A low to moderate inter-rater agreement was observed, mainly due to a lack of standardized models to describe ICPs for dementias. Results suggest that policy- and decision-makers should pay more attention to the GICPD when producing ICPs. The direct communication with clinicians, and the implementation of more precise and appropriate clinical outcomes, could increase the involvement of clinicians, whose participation is crucial to guarantee that ICPs meet needs of patients and their carers.

[Dialogues on the work process in oral health in Brazil: an analysis based on the PMAQ-AB survey]. / Diálogos sobre o processo de trabalho em saúde bucal no Brasil: uma análise com base no PMAQ-AB.

The study aimed to: (1) describe the work process in Brazil's oral health teams, based on the essential attributes of primary health care, according to geographic region, type of team, and the municipality's socioeconomic characteristics and (2) verify whether the data in the work process of the oral health teams in the Brazilian National Program to Improve Access and Quality in primary health (PMAQ-AB) were capable of measuring such attributes. This was a nationwide ecological study with data from cycle I of PMAQ-AB. The study included descriptive, exploratory factor, and confirmatory factor analyses (α = 5%). Constructs were analyzed in light of the essential attributes of primary health care (first contact, coordination of care, comprehensiveness, and continuity). The first three constructs and a fourth factor were formed, called dental prosthesis actions. However, the continuity attribute was not formed. The models' goodness-of-fit measures were satisfactory. Factor loads were greater than 0.5, except for the two variables in factor 3. The actions most frequently performed by the oral health teams (> 60%) were in first contact, and the least frequent were those in comprehensiveness, highlighting referrals to specialties (7.6%). There were differences in the work process in oral health teams between regions of the country, type of team, and certification strata (p < 0.05). In conclusion, data on the work process in oral health teams from cycle primary health care in the services' work routine. Further research is recommended on continuity of care. In addition, the oral health teams participating in cycle I of PMAQ-AB should make further progress in actions related to comprehensiveness and coordination of care.

Os objetivos do estudo foram: (1) descrever o processo de trabalho das equipes de saúde bucal (ESB) do Brasil, com base nos atributos essenciais da atenção primária à saúde, segundo regiões, tipo de equipe e características socioeconômicas dos municípios; e (2) verificar se os dados do processo de trabalho das ESB do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB) foram capazes de aferir tais atributos. Estudo ecológico, de abrangência nacional, com dados do ciclo I do PMAQ-AB. Foram feitas análises descritivas, fatoriais exploratória e confirmatória (α = 5%). Os construtos formados foram analisados à luz dos atributos essenciais da atenção primária à saúde (primeiro contato, coordenação do cuidado, integralidade e longitudinalidade). Formaram-se os três primeiros construtos e um quarto fator, denominado ações em prótese dentária. Porém, o atributo longitudinalidade não foi conformado. As medidas de ajuste dos modelos foram satisfatórias. As cargas fatoriais foram maiores que 0,5, exceto para duas variáveis do fator 3. As ações mais realizadas pelas ESB (> 60%) foram as do primeiro contato e as menos comuns foram as da integralidade, destacando-se ter referência para especialidades (7,6%). Houve diferenças no processo de trabalho das ESB entre as regiões, tipo de equipe e estrato de certificação (p < 0,05). Conclui-se que os dados de processo de trabalho das ESB do ciclo I do PMAQ-AB foram capazes de discriminar três dos quatro atributos essenciais da atenção primária à saúde na rotina dos serviços. Sugere-se aprofundar a avaliação da longitudinalidade. Ademais, as ESB participantes do ciclo I do PMAQ-AB precisam avançar nas ações relacionadas à integralidade e coordenação do cuidado.

Los objetivos de este trabajo fueron: (1) describir el proceso de trabajo de los equipos de salud bucal (ESB) en Brasil, conforme los atributos esenciales de la atención primaria a la salud, según regiones, tipo de equipo y características socioeconómicas de los municipios; además de (2) verificar si los datos del proceso de trabajo de las ESB en el Programa Nacional de Mejora del Acceso y Calidad de la Atención Básica (PMAQ-AB) fueron capaces de evaluar tales atributos. Es un estudio ecológico, de cobertura nacional, con datos del ciclo I del PMAQ-AB. Se realizaron análisis descriptivos, factoriales exploratorios y confirmatorios (α = 5%). Los constructos creados se analizaron a la luz de los atributos esenciales de la atención primaria a la salud (primer contacto, coordinación del cuidado, integralidad y longitudinalidad). Se generaron los tres primeros constructos, y un cuarto factor, denominado acciones en prótesis dental. No obstante, el atributo longitudinalidad no se configuró. Las medidas de ajuste de los modelos fueron satisfactorias. Las cargas factoriales fueron mayores que 0,5, excepto en dos variables del factor 3. Las acciones más realizadas por las ESB (> 60%) fueron las de primer contacto, y las menos comunes fueron las de integralidad, destacándose contar con referencias para especialidades (7,6%). Hubo diferencias en el proceso de trabajo de las ESB entre las regiones, tipo de equipo y extracto de certificación (p < 0,05). Se concluye que los datos del proceso de trabajo de las ESB del ciclo I del PMAQ-AB fueron capaces de discriminar tres de los cuatro atributos esenciales de la atención primaria a la salud en la rutina de los servicios. Se sugiere profundizar en la evaluación de la longitudinalidad. Además, las ESB participantes del ciclo I del PMAQ-AB necesitan avanzar en acciones relacionadas con la integralidad y coordinación del cuidado.

Diálogos sobre o processo de trabalho em saúde bucal no Brasil: uma análise com base no PMAQ-AB / Dialogues on the work process in oral health in Brazil: an analysis based on the PMAQ-AB survey / Discusiones sobre el proceso de trabajo en el ámbito de la salud bucal en Brasil: un análisis basado en el PMAQ-AB

Resumo: Os objetivos do estudo foram: (1) descrever o processo de trabalho das equipes de saúde bucal (ESB) do Brasil, com base nos atributos essenciais da atenção primária à saúde, segundo regiões, tipo de equipe e características socioeconômicas dos municípios; e (2) verificar se os dados do processo de trabalho das ESB do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB) foram capazes de aferir tais atributos. Estudo ecológico, de abrangência nacional, com dados do ciclo I do PMAQ-AB. Foram feitas análises descritivas, fatoriais exploratória e confirmatória (α = 5%). Os construtos formados foram analisados à luz dos atributos essenciais da atenção primária à saúde (primeiro contato, coordenação do cuidado, integralidade e longitudinalidade). Formaram-se os três primeiros construtos e um quarto fator, denominado ações em prótese dentária. Porém, o atributo longitudinalidade não foi conformado. As medidas de ajuste dos modelos foram satisfatórias. As cargas fatoriais foram maiores que 0,5, exceto para duas variáveis do fator 3. As ações mais realizadas pelas ESB (> 60%) foram as do primeiro contato e as menos comuns foram as da integralidade, destacando-se ter referência para especialidades (7,6%). Houve diferenças no processo de trabalho das ESB entre as regiões, tipo de equipe e estrato de certificação (p < 0,05). Conclui-se que os dados de processo de trabalho das ESB do ciclo I do PMAQ-AB foram capazes de discriminar três dos quatro atributos essenciais da atenção primária à saúde na rotina dos serviços. Sugere-se aprofundar a avaliação da longitudinalidade. Ademais, as ESB participantes do ciclo I do PMAQ-AB precisam avançar nas ações relacionadas à integralidade e coordenação do cuidado.

Abstract: The study aimed to: (1) describe the work process in Brazil's oral health teams, based on the essential attributes of primary health care, according to geographic region, type of team, and the municipality's socioeconomic characteristics and (2) verify whether the data in the work process of the oral health teams in the Brazilian National Program to Improve Access and Quality in primary health (PMAQ-AB) were capable of measuring such attributes. This was a nationwide ecological study with data from cycle I of PMAQ-AB. The study included descriptive, exploratory factor, and confirmatory factor analyses (α = 5%). Constructs were analyzed in light of the essential attributes of primary health care (first contact, coordination of care, comprehensiveness, and continuity). The first three constructs and a fourth factor were formed, called dental prosthesis actions. However, the continuity attribute was not formed. The models' goodness-of-fit measures were satisfactory. Factor loads were greater than 0.5, except for the two variables in factor 3. The actions most frequently performed by the oral health teams (> 60%) were in first contact, and the least frequent were those in comprehensiveness, highlighting referrals to specialties (7.6%). There were differences in the work process in oral health teams between regions of the country, type of team, and certification strata (p < 0.05). In conclusion, data on the work process in oral health teams from cycle primary health care in the services' work routine. Further research is recommended on continuity of care. In addition, the oral health teams participating in cycle I of PMAQ-AB should make further progress in actions related to comprehensiveness and coordination of care.

Resumen: Los objetivos de este trabajo fueron: (1) describir el proceso de trabajo de los equipos de salud bucal (ESB) en Brasil, conforme los atributos esenciales de la atención primaria a la salud, según regiones, tipo de equipo y características socioeconómicas de los municipios; además de (2) verificar si los datos del proceso de trabajo de las ESB en el Programa Nacional de Mejora del Acceso y Calidad de la Atención Básica (PMAQ-AB) fueron capaces de evaluar tales atributos. Es un estudio ecológico, de cobertura nacional, con datos del ciclo I del PMAQ-AB. Se realizaron análisis descriptivos, factoriales exploratorios y confirmatorios (α = 5%). Los constructos creados se analizaron a la luz de los atributos esenciales de la atención primaria a la salud (primer contacto, coordinación del cuidado, integralidad y longitudinalidad). Se generaron los tres primeros constructos, y un cuarto factor, denominado acciones en prótesis dental. No obstante, el atributo longitudinalidad no se configuró. Las medidas de ajuste de los modelos fueron satisfactorias. Las cargas factoriales fueron mayores que 0,5, excepto en dos variables del factor 3. Las acciones más realizadas por las ESB (> 60%) fueron las de primer contacto, y las menos comunes fueron las de integralidad, destacándose contar con referencias para especialidades (7,6%). Hubo diferencias en el proceso de trabajo de las ESB entre las regiones, tipo de equipo y extracto de certificación (p < 0,05). Se concluye que los datos del proceso de trabajo de las ESB del ciclo I del PMAQ-AB fueron capaces de discriminar tres de los cuatro atributos esenciales de la atención primaria a la salud en la rutina de los servicios. Se sugiere profundizar en la evaluación de la longitudinalidad. Además, las ESB participantes del ciclo I del PMAQ-AB necesitan avanzar en acciones relacionadas con la integralidad y coordinación del cuidado.

Improvement in Care and Outcomes for Emergency Medical Service-Transported Patients With ST-Elevation Myocardial Infarction (STEMI) With and Without Prehospital Cardiac Arrest: A Mission: Lifeline STEMI Accelerator Study.

BACKGROUND: Patients with ST-elevation myocardial infarction (STEMI) with out-of-hospital cardiac arrest (OHCA) may benefit from direct transport to a percutaneous cardiac intervention (PCI) hospital but have previously been less likely to bypass local non-PCI hospitals to go to a PCI center. METHODS AND RESULTS: We reported time trends in emergency medical service transport and care of patients with STEMI with and without OHCA included from 171 PCI-capable hospitals in 16 US regions with participation in the Mission: Lifeline STEMI Accelerator program between July 1, 2012, and March 31, 2014. Time trends by quarter were assessed using logistic regression with generalized estimating equations to account for hospital clustering. Of 13 189 emergency medical service-transported patients, 88.7% (N=11 703; 10.5% OHCA) were taken directly to PCI hospitals. Among 1486 transfer-in patients, 21.7% had OHCA. Direct transport to a PCI center for OHCA increased from 74.7% (July 1, 2012) to 83.6% (March 31, 2014) (odds ratio per quarter, 1.07; 95% confidence interval, 1.02-1.14), versus 89.0% to 91.0% for patients without OHCA (odds ratio, 1.03; 95% confidence interval, 0.99-1.07; interaction P=0.23). The proportion with prehospital ECGs increased for patients taken directly to PCI centers (53.9%-61.9% for those with OHCA versus 73.9%-81.9% for those without OHCA; interaction P=0.12). Of 997 patients with OHCA taken directly to PCI hospitals and treated with primary PCI, first medical contact-to-device times within the guideline-recommended goal of ≤90 minutes were met for 34.5% on July 1, 2012, versus 41.8% on March 31, 2014 (51.6% and 56.1%, respectively, for 9352 counterparts without OHCA; interaction P=0.72). CONCLUSIONS: Direct transport to PCI hospitals increased for patients with STEMI with and without OHCA during the 2012 to 2014 Mission: Lifeline STEMI Accelerator program. Proportions with prehospital ECGs and timely reperfusion increased for patients taken directly to PCI hospitals.

Evaluating the scientific basis of quality indicators in colorectal cancer care: A systematic review.

AIM: In colorectal cancer care, many indicators for assessment and improvement of quality of care are being used. These quality indicators serve as national and international benchmarks to compare health care on hospital and patient level. However, the scientific basis of these indicators is often unclear. Therefore, the aim of this systematic review is to examine reported quality indicators used in multidisciplinary colorectal cancer care and categorise these indicators based on scientific evidence. METHODS: We searched PubMed from 2005 to 2015 for original articles reporting on development, evaluation or validation of quality indicators in colorectal cancer care. Included articles were categorised in consensus-based, evidence-based and validation cohort studies. Extracted quality indicators were divided into structure, process and outcome indicators and grouped per discipline(s) involved. RESULTS: From 1163 studies, 41 articles were included: 12 (29%) consensus-based, 7 (17%) evidence-based and 22 (54%) validation cohort studies. In total, we identified 389 reported quality indicators: consensus-based (n = 349), evidence-based (n = 7) and validation (n = 33), respectively. Of all reported indicators, 45% (n = 186) concerned surgical items. The vast majority were process indicators (n = 315; 81%) and the remaining outcome (n = 57; 15%) or structure measurements (n = 17; 4%). Only 5 indicators were reported in the majority (≥7/12 articles) of consensus-based papers and 7 indicators were successfully validated. CONCLUSIONS: There is an abundance of reported colorectal cancer quality indicators, of which the majority are surgical, consensus-based process measures, which have not been validated in cohort studies. There is a need for international consensus on a limited evidence-based data set of validated quality indicators, with a focus on outcome indicators.

The impact of an intervention to improve diabetes management in primary healthcare professionals' practices in Brazil.

AIMS: To evaluate the results of a structured intervention in primary healthcare to improve type 2 diabetes management. METHODS: The intervention was implemented in 2011-2012 in two cities in the State of Pernambuco, Brazil, and evaluated in 2013 by interviewing healthcare professionals about their practices in all primary care facilities of these two cities (intervention group), and of two paired control cities (control group). Comparisons between the intervention and control groups were made using standard parametric tests. RESULTS: The percentage of professionals who measured adherence to treatment, developed educational actions to control high-risk situations or prevent complications, or declared that they "explained" the disease to the patients, was higher in the control group (p<0.05). Multidisciplinary involvement, requests for electrocardiograms and referrals to specialists were also more frequent in the control group (p<0.01). The only differences favoring the intervention group were the higher proportion of nurses (p<0.05) and community health workers (p<0.01) trained for diabetes management and a greater frequency of discussing the cases of diabetic patients at team meetings (p<0.01). CONCLUSIONS: These negative results raise questions about the effectiveness of actions aiming to improve diabetes management in primary care, and reinforce the need for careful evaluation of their impact.

Streamlining Workflow for Endovascular Mechanical Thrombectomy: Lessons Learned from a Comprehensive Stroke Center.

BACKGROUND: Recently, 5 randomized controlled trials confirmed the superiority of endovascular mechanical thrombectomy (EMT) to intravenous thrombolysis in acute ischemic stroke with large-vessel occlusion. The implication is that our health systems would witness an increasing number of patients treated with EMT. However, in-hospital delays, leading to increased time to reperfusion, are associated with poor clinical outcomes. This review outlines the in-hospital workflow of the treatment of acute ischemic stroke at a comprehensive stroke center and the lessons learned in reduction of in-hospital delays. METHODS: The in-hospital workflow for acute ischemic stroke was described from prehospital notification to femoral arterial puncture in preparation for EMT. Systematic review of literature was also performed with PubMed. RESULTS: The implementation of workflow streamlining could result in reduction of in-hospital time delays for patients who were eligible for EMT. In particular, time-critical measures, including prehospital notification, the transfer of patients from door to computed tomography (CT) room, initiation of intravenous thrombolysis in the CT room, and the mobilization of neurointervention team in parallel with thrombolysis, all contributed to reduction in time delays. CONCLUSIONS: We have identified issues resulting in in-hospital time delays and have reported possible solutions to improve workflow efficiencies. We believe that these measures may help stroke centers initiate an EMT service for eligible patients.

mStroke: "Mobile Stroke"-Improving Acute Stroke Care with Smartphone Technology.

OBJECTIVE: This study aimed to evaluate the effect of method and time of system activation on clinical metrics in cases utilizing the Stop Stroke (Pulsara, Inc.) mobile acute stroke care coordination application. METHODS: A retrospective cohort analysis of stroke codes at 12 medical centers using Stop Stroke from March 2013 to May 2016 was performed. Comparison of metrics (door-to-needle time [DTN] and door-to-CT time [DTC], and rate of DTN ≤ 60 minutes [goal DTN]) was performed between subgroups based on method (emergency medical service [EMS] versus emergency department [ED]) and time of activation. Effects were adjusted for confounders (age, sex, National Institutes of Health Stroke Scale [NIHSS] score) using multiple linear and logistic regression. RESULTS: The final dataset included 2589 cases. Cases activated by EMS were more severe (median NIHSS score 8 versus 4, P < .0001) and more likely to receive recombinant tissue plasminogen activator (20% versus 12%, P < .0001) than those with ED activation. After adjustment, cases with EMS activation had shorter DTC (6.1 minutes shorter, 95% CI [-10.3, -2]) and DTN (12.8 minutes shorter, 95% CI [-21, -4.6]) and were more likely to meet goal DTN (OR 1.83, 95% CI [1.1, 3]). Cases between 1200 and 1800 had longer DTC (7.7 minutes longer, 95% CI [2.4, 13]) and DTN (21.1 minutes longer, 95% CI [9.3, 33]), and reduced rate of goal DTN (OR .3, 95% CI [.15, .61]) compared to those between 0000 and 0600. CONCLUSIONS: Incorporating real-time prehospital data obtained via smartphone technology provides unique insight into acute stroke codes. Activation of mobile electronic stroke coordination in the field appears to promote a more expedited and successful care process.

Development and Psychometric Properties of a Scale to Measure Hospital Organizational Culture for Cardiovascular Care.

BACKGROUND: Because organizational culture is increasingly understood as fundamental to achieving high performance in hospital and other healthcare settings, the ability to measure this nuanced concept empirically has gained importance. Aside from measures of patient safety culture, no measure of organizational culture has been widely endorsed in the medical literature, limiting replication of previous findings and broader use in interventional studies. METHODS AND RESULTS: We sought to develop and assess the validity and reliability of a scale for assessing organizational culture in the context of hospitals' efforts to reducing 30-day risk-standardized mortality after acute myocardial infarction. The 31-item scale was completed by 147 individuals representing 10 hospitals during August and September 2014. The resulting organizational culture scale demonstrated high level of construct validity and internal consistency. Factor analyses indicated that the 31 items loaded well (loading values 0.48-0.90), supporting distinguishable domains of (1) learning environment, (2) psychological safety, (3) commitment to the organization, (4) senior management support, and (5) time for improvement efforts. Cronbach α coefficients were 0.94 for the scale and ranged from 0.77 to 0.88 for the subscales. The scale displayed reasonable convergent validity and statistically significant variability across hospitals, with hospital identity accounting for 11.3% of variance in culture scores across respondents. CONCLUSIONS: We developed and validated a relatively easy-to-administer survey that was able to detect substantial variability in organizational culture across different hospitals and may be useful in measuring hospital culture and evaluating changes in culture over time as part performance improvement efforts.

Association of Rapid Care Process Implementation on Reperfusion Times Across Multiple ST-Segment-Elevation Myocardial Infarction Networks.

BACKGROUND: The Mission: Lifeline STEMI Systems Accelerator program, implemented in 16 US metropolitan regions, resulted in more patients receiving timely reperfusion. We assessed whether implementing key care processes was associated with system performance improvement. METHODS AND RESULTS: Hospitals (n=167 with 23 498 ST-segment-elevation myocardial infarction patients) were surveyed before (March 2012) and after (July 2014) program intervention. Data were merged with patient-level clinical data over the same period. For reperfusion, hospitals were grouped by whether a specific process of care was implemented, preexisting, or never implemented. Uptake of 4 key care processes increased after intervention: prehospital catheterization laboratory activation (62%-91%; P<0.001), single call transfer protocol from an outside facility (45%-70%; P<0.001), and emergency department bypass for emergency medical services direct presenters (48%-59%; P=0.002) and transfers (56%-79%; P=0.001). There were significant differences in median first medical contact-to-device times among groups implementing prehospital activation (88 minutes implementers versus 89 minutes preexisting versus 98 minutes nonimplementers; P<0.001 for comparisons). Similarly, patients treated at hospitals implementing single call transfer protocols had shorter median first medical contact-to-device times (112 versus 128 versus 152 minutes; P<0.001). Emergency department bypass was also associated with shorter median first medical contact-to-device times for emergency medical services direct presenters (84 versus 88 versus 94 minutes; P<0.001) and transfers (123 versus 127 versus 167 minutes; P<0.001). CONCLUSIONS: The Accelerator program increased uptake of key care processes, which were associated with improved system performance. These findings support efforts to implement regional ST-segment-elevation myocardial infarction networks focused on prehospital catheterization laboratory activation, single call transfer protocols, and emergency department bypass.

Fixing the broken image of care homes, could a 'care home innovation centre' be the answer?

The UK has many excellent care homes that provide high-quality care for their residents; however, across the care home sector, there is a significant need for improvement. Even though the majority of care homes receive a rating of 'good' from regulators, still significant numbers are identified as requiring 'improvement' or are 'inadequate'. Such findings resonate with the public perceptions of long-term care as a negative choice, to be avoided wherever possible-as well as impacting on the career choices of health and social care students. Projections of current demographics highlight that, within 10 years, the part of our population that will be growing the fastest will be those people older than 80 years old with the suggestion that spending on long-term care provision needs to rise from 0.6% of our Gross Domestic Product in 2002 to 0.96% by 2031. Teaching/research-based care homes have been developed in the USA, Canada, Norway, the Netherlands and Australia in response to scandals about care, and the shortage of trained geriatric healthcare staff. There is increasing evidence that such facilities help to reduce inappropriate hospital admissions, increase staff competency and bring increased enthusiasm about working in care homes and improve the quality of care. Is this something that the UK should think of developing? This commentary details the core goals of a Care Home Innovation Centre for training and research as a radical vision to change the culture and image of care homes, and help address this huge public health issue we face.

Comparing guideline-based care quality for inflammatory bowel disease and rheumatoid arthritis patients within a medical home.

BACKGROUND: Rheumatoid arthritis (RA) and inflammatory bowel disease (IBD) patient populations face similar risks of chronic immunosuppression including corticosteroid use. We compared the receipt of preventive services between IBD and RA populations according to published quality metrics. METHODS: We defined a single-center cohort of patients with IBD or RA receiving specialty and primary care. Electronic health record abstraction assessed quality metrics, sociodemographics, comorbidity, and utilization. Comparisons used multivariate odds ratios and Student's t-tests. RESULTS: 218 RA and 190 IBD patients were included. In multivariate analysis, IBD patients were less likely to receive pneumococcal vaccination (OR=0.29, 95% CI: 0.11-0.85), while RA patients underwent glucocorticoid-induced osteoporosis screening more often (100% vs. 82.5%, p = 0.023). CONCLUSIONS: Gastroenterologists can improve care quality for IBD patients by assuming greater responsibility for preventive care in IBD patients and/or collaborating with primary care and health systems to improve preventive care delivery.

Can improved quality of care explain the success of orthogeriatric units? A population-based cohort study.

BACKGROUND: admission to orthogeriatric units improves clinical outcomes for patients with hip fracture; however, little is known about the underlying mechanisms. OBJECTIVE: to compare quality of in-hospital care, 30-day mortality, time to surgery (TTS) and length of hospital stay (LOS) among patients with hip fracture admitted to orthogeriatric and ordinary orthopaedic units, respectively. DESIGN: population-based cohort study. MEASURES: using prospectively collected data from the Danish Multidisciplinary Hip Fracture Registry, we identified 11,461 patients aged ≥65 years admitted with a hip fracture between 1 March 2010 and 30 November 2011. The patients were divided into two groups: (i) those treated at an orthogeriatric unit, where the geriatrician is an integrated part of the multidisciplinary team, and (ii) those treated at an ordinary orthopaedic unit, where geriatric or medical consultant service are available on request. Outcome measures were the quality of care as reflected by six process performance measures, 30-day mortality, the TTS and the LOS. Data were analysed using log-binomial, linear and logistic regression controlling for potential confounders. RESULTS: admittance to orthogeriatric units was associated with a higher chance for fulfilling five out of six process performance measures. Patients who were admitted to an orthogeriatric unit experienced a lower 30-day mortality (adjusted odds ratio (aOR) 0.69; 95% CI 0.54-0.88), whereas the LOS (adjusted relative time (aRT) of 1.18; 95% CI 0.92-1.52) and the TTS (aRT 1.06; 95% CI 0.89-1.26) were similar. CONCLUSIONS: admittance to an orthogeriatric unit was associated with improved quality of care and lower 30-day mortality among patients with hip fracture.

Using Data to Improve Quality: the Pediatric Cardiac Care Consortium.

A program to collect and analyze cardiac catheterization, electrophysiologic studies and cardiac operations in children was initiated in 1982. The purpose was to help centers compare their experience and outcomes with a group of centers to determine areas where their performance might improve. Cardiac centers became members of the Pediatric Cardiac Care Consortium and submitted demographic data and copies of procedure reports regularly to a central office. Data were extracted from the reports, coded by trained coders and entered into a computer database. Annually, the data were analyzed to compare the experience of an individual center with that of the entire group of centers. The annual data were adjusted for severity on the basis of eight factors selected after discussion with participants in the Consortium. Adjustment was by multivariate analysis. Reports were prepared for each center and distributed at an annual meeting. The data were used by centers to review operations where the mortality rate exceeded +2 standard deviations of the group. With discussion, the center staff often initiated changes to improve outcome. The outcome could then be monitored by the annual reports. Our data were also utilized in the creation of the Risk Adjustment for Surgery for Congenital Heart Disease (RACHS)-1 categories of disease severity. The mortality rates of our centers were comparable with the combined hospital discharge data from New York, Massachusetts, and California. From 1982 through 2007, the mortality rates of our centers dropped for each RACHS-1 category, falling to less than 1% for categories 1 and 2 for the last 5-year period. During the 25 years, we received data from 52 centers about 137 654 patients who underwent 117 756 cardiac operations.