Panorama da acreditação (inter)nacional no Brasil / Panorama de la acreditación (inter) nacional en Brasil / Overview of (inter)national accreditation in Brazil

RESUMO Objetivo delinear o panorama da Acreditação nacional e internacional no Brasil. Método estudo descritivo, de abordagem quantitativa e fonte documental. Os campos de inquérito foram as páginas online de acesso irrestrito das seguintes metodologias acreditadoras: Organização Nacional de Acreditação (ONA), Joint Commission International (JCI), Accreditation Canada International (ACI) e QMentum Internacional, além da página do Cadastro Nacional de Estabelecimentos de Saúde (CNES) e/ou sites institucionais. Foram extraídas as variáveis: tipo de instituição/estabelecimento de saúde; regime de gestão setorial; localidade; nível de certificação (em caso de selo concedido pela ONA) e porte (para hospitais). Empregou-se análise estatística descritiva. Resultados apuraram-se os dados de 1.122 certificações, especialmente da ONA (77,2%) e QMentum International (13,2%). Os hospitais prevaleceram na adesão à Acreditação (35,3%), principalmente os de grande porte (60,3%) e do setor privado (75,8%). Houve concentração dos selos de qualidade na região Sudeste do Brasil (64,5%), e a região Norte apresentou menor proporção de estabelecimentos certificados (3%). Conclusões e implicações para a prática as certificações de Acreditação no Brasil remetem à metodologia nacional, com enfoque na área hospitalar privada e na região Sudeste do país. O mapeamento delineado pode sustentar assertividade em políticas de incentivo à gestão da qualidade e avaliação externa no Brasil.

RESUMEN Objetivo delinear el panorama de la Acreditación nacional e internacional en Brasil. Método estudio descriptivo, con enfoque cuantitativo y fuente documental. Los campos de consulta fueron las páginas en línea de libre acceso de las siguientes metodologías de acreditación: Organización Nacional de Acreditación (ONA), Joint Commission International (JCI), Accreditation Canada International (ACI) y QMentum Internacional, además del Registro Nacional de Establecimientos Salud (CNES) y/o sitios web institucionales. Se extrajeron las variables: tipo de institución/establecimiento de salud; régimen de gestión sectorial; localidad; nivel de certificación (en caso de sello otorgado por la ONA) y tamaño (para hospitales). Se utilizó análisis estadístico descriptivo. Resultados se recogieron datos de 1.122 certificaciones, especialmente de ONA (77,2%) y QMentum International (13,2%). Los hospitales prevalecieron en la adhesión a la Acreditación (35,3%), en especial los hospitales grandes (60,3%) y el sector privado (75,8%). Hubo concentración de sellos de calidad en la región Sudeste de Brasil (64,5%), y la región Norte tuvo la menor proporción de establecimientos certificados (3%). Conclusiones e implicaciones para la práctica las certificaciones de acreditación en Brasil se refieren a la metodología nacional, con foco en el área hospitalaria privada y la región Sudeste del país. El mapeo esbozado puede apoyar la asertividad en las políticas de fomento de la gestión de la calidad y la evaluación externa en Brasil.

ABSTRACT Objective to outline the panorama of national and international Accreditation in Brazil. Method a descriptive study, of quantitative approach and documental source. The survey fields were the unrestricted access online pages of the following accrediting methodologies: National Accreditation Organization (ONA), Joint Commission International (JCI), Accreditation Canada International (ACI), and QMentum International, besides the page of the National Registry of Health Establishments (CNES) and/or institutional sites. Variables were extracted: type of institution/health care facility; sector management regime; location; level of certification (in case of a seal granted by ONA), and size (for hospitals). Descriptive statistical analysis was used. Results data from 1,122 certifications was obtained, especially from ONA (77.2%) and QMentum International (13.2%). Hospitals prevailed in the Accreditation adherence (35.3%), mainly the large ones (60.3%) and from the private sector (75.8%). There was a concentration of quality seals in the Southeast region of Brazil (64.5%), and the North region presented the lowest proportion of certified establishments (3%). Conclusions and implications for practice the Accreditation certifications in Brazil refer to the national methodology, focusing on the private hospital area and the Southeast region of the country. The mapping outlined can support assertiveness in incentive policies for quality management and external evaluation in Brazil.

Use of social service counseling by cancer patients: an analysis of quality assurance data of 6339 breast cancer patients from 13 certified centers in Germany treated between 2015 and 2017.

BACKGROUND: Integrated social care may help to mitigate social risk factors in order to achieve more equitable health outcomes. In cancer centers certified according to the criteria set out by the German Cancer Society, every patient must be given low-threshold access to qualified social workers at the center for in-house social service counseling (SSC). Previous analyses have demonstrated large variation in the utilization of these services across individual centers. Therefore, this research aims at investigating whether SSC utilization varies regarding breast cancer patient characteristics and center characteristics presenting a unique approach of using routine data. METHODS: Multilevel modeling was performed using quality assurance data based on 6339 patients treated in 13 certified breast cancer centers in Germany in order to investigate whether SSC utilization varies with patient sex, age, and disease characteristics as well as over time and across centers. RESULTS: In the sample, 80.3% of the patients used SSC. SSC use varies substantially between centers for the unadjusted model (ICC = 0.24). Use was statistically significantly (P < .001) more likely in women, patients with invasive (in comparison to tumor in situ/ductal carcinoma in situ) diseases (P < .001), patients with both breasts affected (P = .03), patients who received a surgery (P < .001), patients who were diagnosed in 2015 or 2017 compared to 2016 (P < .001) and patients older than 84 years as compared to patients between 55 and 64 years old (P = .002). CONCLUSION: The analysis approach allows a unique insight into the reality of cancer care. Sociodemographic and disease-related patient characteristics were identified to explain SSC use to some extent.

A comparison of perioperative outcomes between extraperitoneal robotic single-port and multiport radical prostatectomy with the da Vinci Si Surgical System.

To evaluate outcomes between extraperitoneal robotic single-port radical prostatectomy (epR-spRP) and extraperitoneal robotic multiport radical prostatectomy (epR-mpRP) performed with the da Vinci Si Surgical System, comparison was performed between 30 single-port (SP group) and 26 multiport (MP group) cases. Comparisons included operative time, estimated blood loss (EBL), hospital stay, peritoneal violation, pain scores, scar satisfaction, continence, and erectile function. The median operation time and EBL were not different between the two groups. In the SP group, the median operation time of the first 10 patients was obviously longer than that of the latter 20 patients (P < 0.001). The median postoperative hospital stay in the SP group was shorter than that in the MP group (P < 0.001). The rate of peritoneal damage in the SP group was less than that in the MP group (P = 0.017). The pain score and overall need for pain medications in the SP group were lower than those in the MP group (P < 0.001 and P = 0.015, respectively). Patients in the SP group were more satisfied with their scars than those in the MP group 3 months postoperatively (P = 0.007). At 3 months, the cancer control, recovery of erectile function, and urinary continence rates were similar between the two groups. It is safe and feasible to perform epR-spRP using the da Vinci Si surgical system. Therefore, epR-spRP can be a treatment option for localized prostate cancer. Although epR-spRP still has a learning curve, it has advantages for postoperative pain and self-assessed cosmesis. In the absence of the single-port robotic surgery platform, we can still provide minimally invasive surgery for patients.

Comparing continuous subcutaneous insulin infusion and multiple daily injections in children with Type 1 diabetes in Sweden from 2011 to 2016-A longitudinal study from the Swedish National Quality Register (SWEDIABKIDS).

OBJECTIVE: This study aimed to compare metabolic control measured as hemoglobin A1c (HbA1c), the risk of severe hypoglycemia, and body composition measured as body mass index standard deviation scores (BMI-SDS) in a nationwide sample of children and adolescents with Type 1 diabetes with continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI), respectively. RESEARCH DESIGN AND METHODS: Longitudinal data from 2011 to 2016 were extracted from the Swedish National Quality Register (SWEDIABKIDS) with both cross-sectional (6 years) and longitudinal (4 years) comparisons. Main end points were changes in HbA1c, BMI-SDS, and incidence of severe hypoglycemia. RESULTS: Data were available from 35,624 patient-years (54% boys). In general, HbA1c decreased approximately 0.5% (2-5 mmol/mol) from 2011 to 2016 (ptrend < 0.001) and the use of CSII increased in both sexes and all age groups. Mean HbA1c was 0.1% (0.7-1.5 mmol/mol) lower in the CSII treated group. Teenagers, especially girls, using CSII tended to have higher BMI-SDS. There was no difference in the number of hypoglycemias between CSII and MDI over the years 2011-2016. CONCLUSIONS: There was a small decrease in HbA1c with CSII treatment but of little clinical relevance. Overall, mean HbA1c decreased in both sexes and all age groups without increasing the episodes of severe hypoglycemia, indicating that other factors than insulin method contributed to a better metabolic control.

Relationship Between Perioperative Outcomes Used for Profiling Hospital Noncardiac Surgical Quality.

BACKGROUND: Risk-adjusted morbidity and mortality are commonly used by national surgical quality improvement (QI) programs to measure hospital-level surgical quality. However, the degree of hospital-level correlation between mortality, morbidity, and other perioperative outcomes (like reoperation) collected by contemporary surgical QI programs has not been well-characterized. MATERIALS AND METHODS: Veterans Affairs (VA) Surgical Quality Improvement Program (VASQIP) data (2015-2016) were used to evaluate hospital-level correlation in performance between risk-adjusted 30-d mortality, morbidity, major morbidity, reoperation, and 2 composite outcomes (1- mortality, major morbidity, or reoperation; 2- mortality or major morbidity) after noncardiac surgery. Correlation between outcomes rates was evaluated using Pearson's correlation coefficient. Correlation between hospital risk-adjusted performance rankings was evaluated using Spearman's correlation. RESULTS: Based on a median of 232 [IQR 95-331] quarterly surgical cases abstracted by VASQIP, statistical power for identifying 30-d mortality outlier hospitals was estimated between 3.3% for an observed-to-expected ratio of 1.1 and 45.7% for 3.0. Among 230,247 Veterans who underwent a noncardiac operation at 137 VA hospitals, there were moderate hospital-level correlations between various risk-adjusted outcome rates (highest r = 0.40, mortality and composite 1; lowest r = 0.32, mortality and morbidity). When hospitals were ranked based on performance, there was low-to-moderate correlation between rankings on the various outcomes (highest ρ = 0.47, mortality and composite 1; lowest ρ = 0.37, mortality and major morbidity). CONCLUSIONS: Modest hospital-level correlations between perioperative outcomes suggests it may be difficult to identify high (or low) performing hospitals using a single measure. Additionally, while composites of currently measured outcomes may be an efficient way to improve analytic sample size (relative to evaluations based on any individual outcome), further work is needed to understand whether they provide a more robust and accurate picture of hospital quality or whether evaluating performance across a portfolio of individual measures is most effective for driving QI.

Automatic quality assessment for 2D fetal sonographic standard plane based on multitask learning.

ABSTRACT: The quality control of fetal sonographic (FS) images is essential for the correct biometric measurements and fetal anomaly diagnosis. However, quality control requires professional sonographers to perform and is often labor-intensive. To solve this problem, we propose an automatic image quality assessment scheme based on multitask learning to assist in FS image quality control. An essential criterion for FS image quality control is that all the essential anatomical structures in the section should appear full and remarkable with a clear boundary. Therefore, our scheme aims to identify those essential anatomical structures to judge whether an FS image is the standard image, which is achieved by 3 convolutional neural networks. The Feature Extraction Network aims to extract deep level features of FS images. Based on the extracted features, the Class Prediction Network determines whether the structure meets the standard and Region Proposal Network identifies its position. The scheme has been applied to 3 types of fetal sections, which are the head, abdominal, and heart. The experimental results show that our method can make a quality assessment of an FS image within less a second. Also, our method achieves competitive performance in both the segmentation and diagnosis compared with state-of-the-art methods.

United States' experience in nuchal translucency measurement: variation according to provider characteristics in over five million ultrasound examinations.

OBJECTIVE: The Nuchal Translucency Quality Review (NTQR) program has provided standardized education, credentialing and epidemiological monitoring of nuchal translucency (NT) measurements since 2005. Our aim was to review the effect on NT measurement of provider characteristics since the program's inception. METHODS: We evaluated the distribution of NT measurements performed between January 2005 and December 2019, for each of the three primary performance indicators of NT measurement (NT median multiples of the median (MoM), SD of log10 NT MoM and slope of NT with respect to crown-rump length (CRL)) for all providers within the NTQR program with more than 30 paired NT/CRL results. Provider characteristics explored as potential sources of variability included: number of NT ultrasound examinations performed annually (annual scan volume of the provider), duration of participation in the NTQR program, initial credentialing by an alternative pathway, provider type (physician vs sonographer) and number of NT-credentialed providers within the practice (size of practice). Each of these provider characteristics was evaluated for its effect on NT median MoM and geometric mean of the NT median MoM weighted for the number of ultrasound scans, and multiple regression was performed across all variables to control for potential confounders. RESULTS: Of 5 216 663 NT measurements from 9340 providers at 3319 sites, the majority (75%) of providers had an NT median MoM within the acceptable range of 0.9-1.1 and 85.5% had NT median MoM not statistically significantly outside this range. Provider characteristics associated with measurement within the expected range of performance included higher volume of NT scans performed annually, practice at a site with larger numbers of other NT-credentialed providers, longer duration of participation in the NTQR program and alternative initial credentialing pathway. CONCLUSIONS: Annual scan volume, duration of participation in the NTQR program, alternative initial credentialing pathway and number of other NT-credentialed providers within the practice are all associated with outcome metrics indicating quality of performance. It is critical that providers participate in ongoing quality assessment of NT measurement to maintain consistency and precision. Ongoing assessment programs with continuous feedback and education are necessary to maintain quality care. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

High Social Vulnerability and "Textbook Outcomes" after Cancer Operation.

BACKGROUND: The effect of community-level factors on surgical outcomes has not been well examined. We sought to characterize differences in "textbook outcomes" (TO) relative to social vulnerability among Medicare beneficiaries who underwent operations for cancer. METHODS: Individuals who underwent operations for lung, esophageal, colon, or rectal cancer between 2013 and 2017 were identified using the Medicare database, which was merged with the CDC's Social Vulnerability Index (SVI). TO was defined as surgical episodes with the absence of complications, extended length of stay, readmission, and mortality. The association of SVI and TO was assessed using mixed-effects logistic regression. RESULTS: Among 203,800 patients (colon, n = 113,929; lung, n = 70,642; rectal, n = 14,849; and esophageal, n = 4,380), median age was 75 years (interquartile range 70 to 80 years) and the overwhelming majority of patients was White (n = 184,989 [90.8%]). The overall incidence of TO was 56.1% (n = 114,393). The incidence of complications (low SVI: 21.5% vs high SVI: 24.0%) and 90-day mortality (low SVI: 7.0% vs high SVI: 8.4%) were higher among patients from highly vulnerable neighborhoods (both, p < 0.05). In turn, there were lower odds of achieving TO among high-vs low-SVI patients (odds ratio 0.83; 95% CI, 0.78 to 0.87). Although high-SVI White patients had 10% lower odds (95% CI, 0.87 to 0.93) of achieving TO, high-SVI non-White patients were at 22% lower odds (95% CI, 0.71 to 0.85) of postoperative TO. Compared with low-SVI White patients, high-SVI minority patients had 47% increased odds of an extended length of stay, 40% increased odds of a complication, and 23% increased odds of 90-day mortality (all, p < 0.05). CONCLUSIONS: Only roughly one-half of Medicare beneficiaries achieved the composite optimal TO quality metric. Social vulnerability was associated with lower attainment of TO and an increased risk of adverse postoperative surgical outcomes after several common oncologic procedures. The effect of high SVI was most pronounced among minority patients.

CT Abdominal Tomography Indications: Are We All Sticking to the Plan?

OBJECTIVE: Ultra-low radiation dose computed tomography (CT) abdominal tomography was introduced in our institution in 2016 to replace standard abdominal radiography in the investigation of emergency department patients. This project aims to ascertain whether investigation of emergency department patients using ultra-low radiation dose CT abdominal tomography complies with original indication guidelines and/or if there has been any "indication creep" 3 years after inception. METHODS: Retrospective, quality assurance project with research ethics waiver. A review of 200 consecutive patients investigated with CT abdominal tomography between February and May 2017 was performed. This was compared with 200 consecutive patients investigated between February and May 2019. Data analyzed included patient demographics, indication for scan, as well as scan and patient outcomes. RESULTS: In the 2017 group, 29/200 scans were noncompliant with approved indication guidelines. In the 2019 group, 30/200 scans were also noncompliant. There was no statistically significant difference between groups (P < .05) regarding the use of approved indications. Forty of 200 scans performed in 2017 revealed additional findings which are not specifically addressed on the reporting template. Forty-one of 200 scans in 2019 revealed these findings. CONCLUSIONS: There has been no "indication creep" for CT abdominal tomography over time.

Funnel plots of patient-reported outcomes to evaluate health-care quality: Basic principles, pitfalls and considerations.

A funnel plot is a graphical method to evaluate health-care quality by comparing hospital performances on certain outcomes. So far, in nephrology, this method has been applied to clinical outcomes like mortality and complications. However, patient-reported outcomes (PROs; eg, health-related quality of life [HRQOL]) are becoming increasingly important and should be incorporated into this quality assessment. Using funnel plots has several advantages, including clearly visualized precision, detection of volume-effects, discouragement of ranking hospitals and easy interpretation of results. However, without sufficient knowledge of underlying methods, it is easy to stumble into pitfalls, such as overinterpretation of standardized scores, incorrect direct comparisons of hospitals and assuming a hospital to be in-control (ie, to perform as expected) based on underpowered comparisons. Furthermore, application of funnel plots to PROs is accompanied by additional challenges related to the multidimensional nature of PROs and difficulties with measuring PROs. Before using funnel plots for PROs, high and consistent response rates, adequate case mix correction and high-quality PRO measures are required. In this article, we aim to provide insight into the use and interpretation of funnel plots by presenting an overview of the basic principles, pitfalls and considerations when applied to PROs, using examples from Dutch routine dialysis care.

SPRINTing to Innovation: Children's Hospital of Philadelphia's Strategic Approach to Discovering Its Untapped Innovation Potential.

PROBLEM: There is a clear and urgent need for health care innovation in the United States. Hospital employees routinely recognize pain points that affect care delivery and are in a unique position to propose innovative and practical solutions, yet leaders rarely solicit ideas for investment and development from frontline providers and staff, revealing an untapped resource with innovation potential. APPROACH: To address these deficiencies, the Children's Hospital of Philadelphia expanded its innovation infrastructure with the competition-based SPRINT program in 2015. All hospital employees are encouraged to apply with early-stage innovative ideas, and if selected, are provided with business, legal, technical, and scientific project management support to help accelerate their projects toward commercial viability. SPRINT was modeled around 4 core tenets: (1) small, dynamic, and attentive project manager-led teams; (2) low barriers to entry; (3) emphasis on outreach; and (4) fostering innovators. OUTCOMES: Over its first 4 cycles from 2015 to 2018, 271 innovative teams applied to the SPRINT program, which led to support for 30 projects (11% acceptance rate). About a quarter of the projects each year were submitted by physician-led teams (mean 23%), a third by nonphysician clinical providers (mean 33%), and almost half were submitted by employees without direct patient contact (mean 44%). Nurses have emerged as the largest applicant group. Eleven of the SPRINT-supported projects (37%) resulted in commercial endpoints. NEXT STEPS: SPRINT has proven to be an effective model for supporting institution-wide, employee-driven health care innovation, especially among frontline clinical and nonclinical personnel. Critical next steps for the program include a formal cost-benefit analysis and the earlier participation of technology transfer and intellectual property experts to improve the commercialization roadmap for many SPRINT projects.

Monitoring Hospital Performance with Statistical Process Control After Total Hip and Knee Arthroplasty: A Study to Determine How Much Earlier Worsening Performance Can Be Detected.

BACKGROUND: Given the low early revision rate after total hip arthroplasty (THA) and total knee arthroplasty (TKA), hospital performance is typically compared using 3 years of data. The purpose of this study was to assess how much earlier worsening hospital performance in 1-year revision rates after THA and TKA can be detected. METHODS: All 86,468 THA and 73,077 TKA procedures performed from 2014 to 2016 and recorded in the Dutch Arthroplasty Register were included. Negative outlier hospitals were identified by significantly higher O/E (observed divided by expected) 1-year revision rates in a funnel plot. Monthly Shewhart p-charts (with 2 and 3-sigma control limits) and cumulative sum (CUSUM) charts (with 3.5 and 5 control limits) were constructed to detect a doubling of revisions (odds ratio of 2), generating a signal when the control limit was reached. The median number of months until generation of a first signal for negative outliers and the number of false signals for non-negative outliers were calculated. Sensitivity, specificity, and accuracy were calculated for all charts and control limit settings using outlier status in the funnel plot as the gold standard. RESULTS: The funnel plot showed that 13 of 97 hospitals had significantly higher O/E 1-year revision rates and were negative outliers for THA and 7 of 98 hospitals had significantly higher O/E 1-year revision rates and were negative outliers for TKA. The Shewhart p-chart with the 3-sigma control limit generated 68 signals (34 false-positive) for THA and 85 signals (63 false-positive) for TKA. The sensitivity for THA and TKA was 92% and 100%, respectively; the specificity was 69% and 51%, respectively; and the accuracy was 72% and 54%, respectively. The CUSUM chart with a 5 control limit generated 18 signals (1 false-positive) for THA and 7 (1 false-positive) for TKA. The sensitivity was 85% and 71% for THA and TKA, respectively; the specificity was 99% for both; and the accuracy was 97% for both. The Shewhart p-chart with a 3-sigma control limit generated the first signal for negative outliers after a median of 10 months (interquartile range [IQR] = 2 to 18) for THA and 13 months (IQR = 5 to 18) for TKA. The CUSUM chart with a 5 control limit generated the first signal after a median of 18 months (IQR = 7 to 22) for THA and 21 months (IQR = 9 to 25) for TKA. CONCLUSIONS: Monthly monitoring using CUSUM charts with a 5 control limit enables earlier detection of worsening 1-year revision rates with accuracy so that initiatives to improve care can start earlier.

Possibilities for Quality Assessment of Health Services in Therapeutic Rehabilitation.

The main goal of therapeutic rehabilitation is to provide services that develop, maintain or restore mobility and functionality to the fullest extent possible throughout the patient's life. This process should involve setting real goals both for the person who has mobility and functionality impairment as well as in the records of relevant therapeutic programme objectives. In evaluating this process, quality indicators can be used as 'tools' and they may also be used as parameters for quantitative characterization of healthcare processes and outcomes. The purpose of this paper is to systematise existing knowledge about quality in healthcare in the context of therapeutic rehabilitation, presenting a possible assessment of the level and degree of completion of goals through quality indicators.

Safety practices and opportunities for improvement in brachytherapy: A patient safety practices survey of the American Brachytherapy Society membership.

PURPOSE: Safe delivery of brachytherapy and establishing a safety culture are critical in high-quality brachytherapy. The American Brachytherapy Society (ABS) Quality and Safety Committee surveyed members regarding brachytherapy services offered, safety practices during treatment, quality assurance procedures, and needs to develop safety and training materials. METHODS AND MATERIALS: A 22-item survey was sent to ABS membership in early 2019 to physicians, physicists, therapists, nurses, and administrators. Participation was voluntary. Responses were summarized with descriptive statistics and relative frequency distributions. RESULTS: There were 103 unique responses. Approximately one in three was attending physicians and one in three attending physicists. Most were in practice >10 years. A total of 94% and 50% performed gynecologic and prostate brachytherapy, respectively. Ninety-one percent performed two-identification patient verification before treatment. Eighty-six percent performed a time-out. Ninety-five percent had an incident reporting or learning system, but only 71% regularly reviewed incidents. Half reviewed safety practices within the last year. Twenty percent reported they were somewhat or not satisfied with department safety culture, but 92% of respondents were interested in improving safety culture. Most reported time, communication, and staffing as barriers to improving safety. Most respondents desired safety-oriented webinars, self-assessment modules, learning modules, or checklists endorsed by the ABS to improve safety practice. CONCLUSIONS: Most but not all practices use standards and quality assurance procedures in line with society recommendations. There is a need to heighten safety culture at many departments and to shift resources (e.g., time or staffing) to improve safety practice. There is a desire for society guidance to improve brachytherapy safety practices. This is the first survey to assess safety practice patterns among a national sample of radiation oncologists with expertise in brachytherapy.

Quality assurance assessment of a specialized perinatal mental health clinic.

BACKGROUND: Mood and anxiety issues are the main mental health complaints of women during pregnancy and the postpartum period. Services targeting such women can reduce perinatal complications related to psychiatric difficulties. This quality assurance project aimed to examine changes in mood and anxiety symptoms in pregnant and postpartum women referred to the Women's Health Concerns Clinic (WHCC), a specialized outpatient women's mental health program. METHODS: We extracted patient characteristics and service utilization from electronic medical records of women referred between 2015 and 2016. We also extracted admission and discharge scores on the Edinburgh Postnatal Depression Scale (EPDS) and the Generalized Anxiety Disorder-7 (GAD-7) scale. RESULTS: Most patients accessed the WHCC during pregnancy (54%), had a diagnosis of major depressive disorder (54.9%), were prescribed a change in their medication or dose (61.9%), and accessed psychotherapy for perinatal anxiety (30.1%). There was a significant decrease in EPDS scores between admission and discharge (t(214) = 11.57; p = .000; effect size d = .86), as well as in GAD-7 scores (t(51) = 3.63; p = .001; effect size d = .61). A secondary analysis showed that patients with more severe depression and anxiety symptoms demonstrated even greater effect sizes. CONCLUSIONS: Changes in EPDS and GAD-7 scores indicate that the WHCC is effective in reducing mood and anxiety symptoms associated with the perinatal period. This project highlights the importance of quality assurance methods in evaluating the effectiveness of clinical services targeting perinatal mental health, in order to inform policy and funding strategies.

Results from the WHO external quality assessment for the respiratory syncytial virus pilot, 2016-17.

BACKGROUND: External quality assessments (EQAs) for the molecular detection of respiratory syncytial virus (RSV) are necessary to ensure the provision of reliable and accurate results. One of the objectives of the pilot of the World Health Organization (WHO) Global RSV Surveillance, 2016-2017, was to evaluate and standardize RSV molecular tests used by participating countries. This paper describes the first WHO RSV EQA for the molecular detection of RSV. METHODS: The WHO implemented the pilot of Global RSV Surveillance based on the WHO Global Influenza Surveillance and Response System (GISRS) from 2016 to 2018 in 14 countries. To ensure standardization of tests, 13 participating laboratories were required to complete a 12 panel RSV EQA prepared and distributed by the Centers for Disease Control and Prevention (CDC), USA. The 14th laboratory joined the pilot late and participated in a separate EQA. Laboratories evaluated a RSV rRT-PCR assay developed by CDC and compared where applicable, other Laboratory Developed Tests (LDTs) or commercial assays already in use at their laboratories. RESULTS: Laboratories performed well using the CDC RSV rRT-PCR in comparison with LDTs and commercial assays. Using the CDC assay, 11 of 13 laboratories reported correct results. Two laboratories each reported one false-positive finding. Of the laboratories using LDTs or commercial assays, results as assessed by Ct values were 100% correct for 1/5 (20%). With corrective actions, all laboratories achieved satisfactory outputs. CONCLUSIONS: These findings indicate that reliable results can be expected from this pilot. Continued participation in EQAs for the molecular detection of RSV is recommended.

Association of Do-Not-Resuscitate Patient Case Mix With Publicly Reported Risk-Standardized Hospital Mortality and Readmission Rates.

Importance: The Centers for Medicare and Medicaid Services's (CMS's) 30-day risk-standardized mortality rate (RSMR) and risk-standardized readmission rate (RSRR) models do not adjust for do-not-resuscitate (DNR) status of hospitalized patients and may bias Hospital Readmissions Reduction Program (HRRP) financial penalties and Overall Hospital Quality Star Ratings. Objective: To identify the association between hospital-level DNR prevalence and condition-specific 30-day RSMR and RSRR and the implications of this association for HRRP financial penalty. Design, Setting, and Participants: This cross-sectional study obtained patient-level data from the Medicare Limited Data Set Inpatient Standard Analytical File and hospital-level data from the CMS Hospital Compare website for all consecutive Medicare inpatient encounters from July 1, 2015, to June 30, 2018, in 4484 US hospitals. Hospitalized patients had a principal diagnosis of acute myocardial infarction (AMI), heart failure (HF), stroke, pneumonia, or chronic obstructive pulmonary disease (COPD). Incoming acute care transfers, discharges against medical advice, and patients coming from or discharged to hospice were among those excluded from the analysis. Exposures: Present-on-admission (POA) DNR status was defined as an International Classification of Diseases, Ninth Revision diagnosis code of V49.86 (before October 1, 2015) or as an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis code of Z66 (beginning October 1, 2015). Hospital-level prevalence of POA DNR status was calculated for each of the 5 conditions. Main Outcomes and Measures: Hospital-level 30-day RSMRs and RSRRs for 5 condition-specific cohorts (mortality cohorts: AMI, HF, stroke, pneumonia, and COPD; readmission cohorts: AMI, HF, pneumonia, and COPD) and HRRP financial penalty status (yes or no). Results: Included in the study were 4 884 237 inpatient encounters across condition-specific 30-day mortality cohorts (patient mean [SD] age, 78.8 [8.5] years; 2 608 182 women [53.4%]) and 4 450 378 inpatient encounters across condition-specific 30-day readmission cohorts (patient mean [SD] age, 78.6 [8.5] years; 2 349 799 women [52.8%]). Hospital-level median (interquartile range [IQR]) prevalence of POA DNR status in the mortality cohorts varied: 11% (7%-16%) for AMI, 13% (7%-23%) for HF, 14% (9%-22%) for stroke, 17% (9%-26%) for pneumonia, and 10% (5%-18%) for COPD. For the readmission cohorts, the hospital-level median (IQR) POA DNR prevalence was 9% (6%-15%) for AMI, 12% (6%-22%) for HF, 16% (8%-24%) for pneumonia, and 9% (4%-17%) for COPD. The 30-day RSMRs were significantly higher for hospitals in the highest quintiles vs the lowest quintiles of DNR prevalence (eg, AMI: 12.9 [95% CI, 12.8-13.1] vs 12.5 [95% CI, 12.4-12.7]; P < .001). The inverse was true among the readmission cohorts, with the highest quintiles of DNR prevalence exhibiting the lowest RSRRs (eg, AMI: 15.3 [95% CI, 15.1-15.5] vs 15.9 [95% CI, 15.7-16.0]; P < .001). A 1% absolute increase in risk-adjusted hospital-level DNR prevalence was associated with greater odds of avoiding HRRP financial penalty (odds ratio, 1.06; 95% CI, 1.04-1.08; P < .001). Conclusions and Relevance: This cross-sectional study found that the lack of adjustment in CMS 30-day RSMR and RSRR models for POA DNR status of hospitalized patients may be associated with biased readmission penalization and hospital-level performance.

[Theoretic and practical contribution of bayesian inference to statistical process control: The experience of the Lyon Hospitals Board hemostasis laboratory]. / Intérêts théoriques et pratiques de l'inférence bayésienne dans la maîtrise statistique des procédés : retours d'expérience du laboratoire d'hémostase aux Hospices civils de Lyon.

Laboratories need to set up effective overall management of their internal quality control (IQC) and external quality assessment (EQA) results as key elements in statistical process control. Quality targets need to be defined, with methods to ensure durable control with respect to the relevant specifications. The hemostasis laboratory of the Lyon Hospitals Board (HCL, Lyon, France) uses model 3 from the Milan consensus conference, which is the state of the art in terms of quality targets, and uses a common EQA provider supplying as many real patient samples as possible. Giving priority to adopted methods, the lab optimizes the use of manufacturers' prior data: maximum acceptable inter assay coefficient of variation (CV) and prior IQC target values. Bayesian inference brings the method under control with respect to the manufacturers' prior data without the need for a preliminary phase. It links the IQC and EQA plans by the maximum acceptable CVs defined by the manufacturer.

Quality Assessment of Intraoperative Adverse Event Reporting During 29 227 Robotic Partial Nephrectomies: A Systematic Review and Cumulative Analysis.

The definition of intraoperative adverse events (IAEs) still lacks standardization, hampering the assessment of surgical performance in this regard. Over the years, efforts to address this issue have been carried out to improve the reporting of outcomes. In 2019, the European Association of Urology (EAU) proposed a standardized reporting tool for IAEs in urology. The objective of the present study is to distill systematically published data on IAEs in patients undergoing robotic partial nephrectomy (RPN) for renal masses to answer three key questions (KQs). (KQ1) Which system is used to report the IAEs? (KQ2) What is the frequency of IAEs? (KQ3) What types of IAEs are reported? A comprehensive systematic review of all English-language publications on RPN was carried out. We followed the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines to evaluate PubMed, Scopus, and Web of Science databases (from January 1, 2000 to January 1, 2019). Quality of reporting and grading complications were assessed according to the EAU recommendations. Globally, 59 (35.3%) and 108 (64.7%) studies reported zero and one or more IAEs, respectively. Overall, 761 (2.6%) patients reported at least one IAE. Intraoperative bleeding is reported as the most common IAE (58%). Our analysis showed no improvement in reporting and grading of IAEs over time. PATIENT SUMMARY: Up to now, an agreement regarding the definition and reporting of intraoperative adverse events (IAEs) in the literature has not been achieved. The aim of this study is to evaluate the reporting of IAEs in patients undergoing robotic partial nephrectomy (RPN) after a systematic review of the literature. More rigorous reporting of IAEs during RPN is needed to measure their impact on patients' perioperative care.