A comparison of prospective observations and chart audits for measuring quality of care of musculoskeletal injuries in the emergency department.

BACKGROUND: Accurate and efficient data collection is crucial for effective evaluation of quality of care. The objective of this study is to compare two methods of data collection used to score quality indicators for musculoskeletal injury management in Emergency departments: prospective observation, and chart audit. METHODS: An analysis was undertaken of data collected from 633 patients who presented with a musculoskeletal injury to eight emergency departments in Queensland, Australia in 2016-17. Twenty-two quality indicators were scored using both prospective observation and chart audit data for each occasion of service. Quality indicators were included if they were originally published with both collection methods. Analyses were performed to compare firstly, the quality indicator denominators, and secondly, the quality indicator trigger rates, scored using each collection method. Chi Square statistics were used to identify significant differences. RESULTS: Prospectively collected data scored quality indicator denominators significantly (p value<0.05) more often than chart audit data for five (22.7 %) of the 22 quality indicators. The remaining 17 quality indicators (77.3 %) showed no statistical differences. When comparing quality indicator trigger rates, 16 (72.7 %) had significantly different results between methods with 12 (54.5 %) scoring higher using prospective data and four (18.2 %) with chart audit data. The remaining six quality indicators (27.3 %) in this comparison showed no significant difference between chart and prospective data. CONCLUSION: Quality indicators including aspects of care associated with patient safety, and those relying on clinician written orders or forms were adequately scored using either prospective observation or chart audit data. Whereas quality indicators relying on time-sensitive information, elements of a social history, general physical exams and patient education and advice scored higher using prospective observation data collection.

Higher quality of care in emergency departments with physiotherapy service models.

OBJECTIVE: To investigate the quality of care provided by EDs with physiotherapy services compared to those without, using established musculoskeletal process and outcome quality indicators (QIs). METHODS: An analysis was undertaken of prospective observational and chart audit data collected from 628 patients who presented with a musculoskeletal injury in any of the eight participating EDs in Queensland in 2016-2017. The care provided was scored against 46 musculoskeletal QIs. Quality of care was first compared between EDs with physiotherapists to EDs with a limited physiotherapy service, and second between EDs with primary contact physiotherapists to EDs without. χ2 and Fisher's exact tests were used to identify significant results. RESULTS: In the first comparison, EDs with physiotherapists performed significantly higher on 15 QIs and EDs with only limited physiotherapy performed higher on two QIs. In the second comparison, EDs with primary contact physiotherapists performed significantly higher on 17 QIs when compared to EDs without and three QIs demonstrated significance in favour of EDs without primary contact physiotherapists. Performance differences occurred across both process and outcome QIs, including musculoskeletal assessment, diagnostics, pain assessment and management, fracture management, medication safety, mobility, patient information, referrals and follow-up, re-presentations and patient experience. CONCLUSIONS: EDs with physiotherapists provide at least equivalent or higher quality of care for patients with musculoskeletal injuries than those EDs with limited access to physiotherapists. This may be because of their specialised training in musculoskeletal diagnosis and treatment, as well as the impact of teaching and mentoring for other ED clinicians.

The Association of Vitamin D Status with Dyslipidaemia and Biomarkers of Endothelial Cell Activation in Older Australians.

BACKGROUND/AIMS: Vitamin D has been investigated for many non-skeletal effects. The objective of this study was to determine whether circulating lipids, systemic inflammation, and biomarkers of endothelial cell activation varied with the vitamin D status of older Australians. METHODS: One hundred and one participants were proportionately and randomly sampled across tertiles of 25 hydroxy vitamin D (25(OH)D) from a larger cohort of free living older adults (T1 median = 97; T2 median = 74.5; T3 median = 56.8 nmol/L). Overnight fasting blood samples were assayed for 25(OH)D, parathyroid hormone (PTH), insulin, triacylglycerol (TAG), total cholesterol (TC), low density lipoprotein cholesterol (LDL-C) and high density lipoprotein cholesterol (HDL-C). Markers of systemic inflammation (high sensitivity C-reactive protein (hsCRP), tumour necrosis factor-α (TNF-α)) and endothelial activation (hepatocyte growth factor (HGF), P-selectin and soluble vascular cell adhesion molecule (sVCAM), soluble intracellular adhesion molecule (sICAM)) were determined. A general linear model multivariate analysis with a backward elimination procedure was performed. RESULTS: Eighty-three participants (48 women, 35 men), aged 65 ± 7.7 years, BMI 28 ± 4.5 kg/m², with complete data were analyzed. The final parsimonious model controlled for age, gender, BMI, and McAuley's index, but excluded season, medications, and PTH. There were significant differences across 25(OH)D tertiles in TC (T1 < T3, p = 0.003; T2 < T3, p = 0.001), LDL-C (T1 < T3, p = 0.005; T2 < T3, p = 0.001), TAG (T2 < T3, p = 0.026), HGF (T1 > T3, p = 0.009) and sVCAM (T1 > T3, P = 0.04). CONCLUSIONS: Higher vitamin D status may protect the endothelium through reduced dyslipidaemia and increased HGF.