Chronic polytherapy after myocardial infarction: the trade-off between hospital and community-based providers in determining adherence to medication.

BACKGROUND: The benefits of chronic polytherapy in reducing readmissions and death after myocardial infarction (MI) have been clearly shown. However, real-world evidence shows poor medication adherence and large geographic variation, suggesting critical issues in access to optimal care. Our objectives were to measure adherence to polytherapy, to compare the amount of variation attributable to hospitals of discharge and to community-based providers, and to identify determinants of adherence to medications. METHODS: This is a population-based study. Data were obtained from the information systems of the Lazio and Tuscany Regions, Italy (9.5 million inhabitants). Patients hospitalized with incident MI in 2010-2014 were analyzed. The outcome measure was medication adherence, defined as a Medication Possession Ratio (MPR) ≥ 0.75 for at least 3 of the following drugs: antiplatelets, ß-blockers, ACEI/ARBs, statins. A 2-year cohort-study was performed. Cross-classified multilevel models were applied to analyze geographic variation. The variance components attributable to hospitals of discharge and community-based providers were expressed as Median Odds Ratio (MOR). RESULTS: A total of 32,962 patients were enrolled. About 63% of patients in the Lazio cohort and 59% of the Tuscan cohort were adherent to chronic polytherapy. Women and patients aged 85 years and over were most at risk of non-adherence. In both regions, adherence was higher for patients discharged from cardiology wards (Lazio: OR = 1.58, p < 0.001, Tuscany: OR = 1.59, p < 0.001) and for patients with a percutaneous coronary intervention during the index admission. Relevant variation between community-based providers was observed, though when the hospital of discharge was included as a cross-classified level, in both Lazio and Tuscany regions the variation attributable to hospitals of discharge was the only significant component (Lazio: MOR = 1.30, p = 0.001; Tuscany: MOR = 1.31, p = 0.001). CONCLUSION: Adherence to best practice treatments after MI is not consistent with clinical guidelines, and varies between patient groups as well as within and between regions. The variation attributable to providers is affected by the hospital of discharge, up to two years from the acute episode. This variation is likely to be attributable to hospital discharge processes, and could be reduced through appropriate policy levers.

Benchmarking experience to improve paediatric healthcare: listening to the voices of families from two European Children's University Hospitals.

BACKGROUND: Patient Reported Experience Measures (PREMs) are recognized as an important indicator of high quality care and person-centeredness. PREMs are increasingly adopted for paediatric care, but there is little published evidence on how to administer, collect, and report paediatric PREMs at scale. METHODS: This paper describes the development of a PREMs questionnaire and administration system for the Meyer Children's University Hospital in Florence (Meyer) and the Children's Clinical University Hospital in Riga (CCUH). The system continuously recruits participants into the electronic administration model, with surveys completed by caregivers or adolescents at their convenience, post-discharge. We analyse 1661 responses from Meyer and 6585 from CCUH, collected from 1st December 2018 to 21st January 2020. Quantitative and qualitative experience analyses are included, using Pearson chi-square tests, Fisher's exact tests and narrative evidence from free text responses. RESULTS: The large populations reached in both countries suggest the continuous, digital collection of paediatric PREMs described is feasible for collecting paediatric PREMs at scale. Overall response rates were 59% in Meyer and 45% in CCUH. There was very low variation in mean scores between the hospitals, with greater clustering of Likert scores around the mean in CCUH and a wider spread in Meyer for a number of items. The significant majority of responses represent the carers' point of view or the perspective of children and adolescents expressed through proxy reporting by carers. CONCLUSIONS: Very similar reported scores may reflect broadly shared preferences among children, adolescents and carers in the two countries, and the ability of both hospitals in this study to meet their expectations. The model has several interesting features: inclusion of a narrative element; electronic administration and completion after discharge from hospital, with high completion rates and easy data management; access for staff and researchers through an online platform, with real time analysis and visualization; dual implementation in two sites in different settings, with comparison and shared learning. These bring new opportunities for the utilization of PREMs for more person-centered and better quality care, although further research is needed in order to access direct reporting by children and adolescents.

Exploring Changes to the Actionability of COVID-19 Dashboards Over the Course of 2020 in the Canadian Context: Descriptive Assessment and Expert Appraisal Study.

BACKGROUND: Public web-based COVID-19 dashboards are in use worldwide to communicate pandemic-related information. Actionability of dashboards, as a predictor of their potential use for data-driven decision-making, was assessed in a global study during the early stages of the pandemic. It revealed a widespread lack of features needed to support actionability. In view of the inherently dynamic nature of dashboards and their unprecedented speed of creation, the evolution of dashboards and changes to their actionability merit exploration. OBJECTIVE: We aimed to explore how COVID-19 dashboards evolved in the Canadian context during 2020 and whether the presence of actionability features changed over time. METHODS: We conducted a descriptive assessment of a pan-Canadian sample of COVID-19 dashboards (N=26), followed by an appraisal of changes to their actionability by a panel of expert scorers (N=8). Scorers assessed the dashboards at two points in time, July and November 2020, using an assessment tool informed by communication theory and health care performance intelligence. Applying the nominal group technique, scorers were grouped in panels of three, and evaluated the presence of the seven defined features of highly actionable dashboards at each time point. RESULTS: Improvements had been made to the dashboards over time. These predominantly involved data provision (specificity of geographic breakdowns, range of indicators reported, and explanations of data sources or calculations) and advancements enabled by the technologies employed (customization of time trends and interactive or visual chart elements). Further improvements in actionability were noted especially in features involving local-level data provision, time-trend reporting, and indicator management. No improvements were found in communicative elements (clarity of purpose and audience), while the use of storytelling techniques to narrate trends remained largely absent from the dashboards. CONCLUSIONS: Improvements to COVID-19 dashboards in the Canadian context during 2020 were seen mostly in data availability and dashboard technology. Further improving the actionability of dashboards for public reporting will require attention to both technical and organizational aspects of dashboard development. Such efforts would include better skill-mixing across disciplines, continued investment in data standards, and clearer mandates for their developers to ensure accountability and the development of purpose-driven dashboards.

Systematic and continuous collection of patient-reported outcomes and experience in women with cancer undergoing mastectomy and immediate breast reconstruction: a study protocol for the Tuscany Region (Italy).

INTRODUCTION: Monitoring how patients feel and what they experience during the care process gives health professionals data to improve the quality of care, and gives health systems information to better design and implement care pathways. To gain new insights about specific gaps and/or strengths in breast cancer care, we measure patient-reported outcomes (PROs) and patient-reported experiences (PREs) for women receiving immediate breast reconstruction (iBR). METHODS AND ANALYSIS: Prospective, multicentre, cohort study with continuous and systematic web-based data collection from women diagnosed with breast cancer, who have an indication for iBR after mastectomy treated at any Breast Unit (BU) in Tuscany Region (Italy). Patients are classified into one of two groups under conditions of routine clinical practice, based on the type of iBR planned (implant and autologous reconstruction). Patient-reported information are obtained prior to and after surgery (at 3-month and 12-month follow-up). We estimate that there are around 700 annual eligible patients.Descriptive analyses are used to assess trends in PROs over time and differences between types of iBR in PROs and PREs. Additionally, econometric models are used to analyse patient and BU characteristics associated with outcomes and experiences. PREs are evaluated to assess aspects of integrated care along the care pathway. ETHICS AND DISSEMINATION: The study has been reviewed and obtained a nihil obstat from the Tuscan Ethics Committees of the three Area Vasta in 2017. Dissemination of results will be via periodic report, journal articles and conference presentations.

Value in Healthcare and the Role of the Patient Voice.

A prevailing feature of recent healthcare delivery and reform initiatives is a focus on increasing the value provided by investment in services, alongside a more nuanced understanding of how such value should be considered. Effective measurement of this value remains an elusive goal for most health system performance assessment (HSPA) systems. A more prominent role for the patient voice can enable a better understanding of value at both patient and population levels. The Tuscan HSPA model has evolved over the past several years by adopting the perspective of service users, including multiple dimensions of performance, and illustrating the interactions of these elements. For the heart failure pathway, this approach has now been further developed to combine these dimensions with the systematic electronic collection of patient-reported outcome measures and patient-reported experience measures - initially in a specialist hospital. This enables a richer understanding of the value delivered by professionals as they operate in reality, as opposed to by organizational boundaries, and more timely and actionable insights into the drivers of that value. This commentary sets out the latest developments in the Tuscan HSPA and the lessons from implementation.