Systematic review and meta-analysis on the effect of hospital competition on quality of care: Implications for senior care.

BACKGROUND: Empirical studies examined the associations between hospital competition and quality of care by using different methodology, measures, patient groups and geographic locations; however, results remained inconclusive. This study aimed to apply meta-analysis to evaluate the effect of hospital competition on quality of care and to explore the potential implications to care for senior patients. METHODS: A systematic review and meta-analysis combining results from various studies to obtain an overall outcome was performed. Measure of effect size, I2 test, meta-regression to find sources of heterogeneity, tests for publication bias, sensitivity analysis and cumulative analysis were performed. The mean effect size is estimated by coefficient and standard error with P values less than 0.05 which was considered statistically significant. RESULTS: Based on the selection criteria, only 11 studies were eligible for this meta-analysis. The pooled effect of hospital competition on quality of care was reported by all of the 11 included studies. Results of the meta-analysis suggested that hospital competition reduced quality of care, but the overall effect was relatively insignificant from a statistical perspective (Point estimate = 0.008, 95% CI = -0.004 ˜ 0.020, P > 0.05). CONCLUSIONS: Hospital competition slightly increased mortality rates of acute myocardial infarction, but not statistically significant. The negative impact may be lessened over time as medical technology, practices, and techniques improve. Older patients with complex care needs may be at risk for poorer quality of care related to hospital competition.

Use of Ultrasound by Internists to Improve Diagnostic Small Joint Aspiration.

BACKGROUND: Primary care internists are often the first to see patients with an initial episode of crystalline arthritis. Timely aspiration of the affected joint for definitive diagnosis and treatment in the office is desirable but can be difficult, especially if the joint is small, surrounded by soft tissue swelling distorting landmarks, and is very painful to move or palpate. METHODS: We compared the likelihood of successful aspiration of the great toe metatarsophalangeal joint by primary care internists for the diagnosis of potential crystalline arthritis by either landmark identification of the joint space or by employing ultrasound to identify the joint space. RESULTS: Aspiration was performed by one of 2 primary care internists using landmarks and palpation to identify the joint space in 27 patients with suspected crystalline arthritis affecting the first metatarsophalangeal joint. A sample adequate for diagnosis by polarized light microscopic crystal analysis was obtained in 14 of the 27 aspirations (52%) when landmarks alone were used to locate the joint space. In an additional 27 patients with suspected crystalline arthritis affecting the first metatarsophalangeal joint, ultrasound was used to identify the joint space and resulted in a significant increase in the success of obtaining an adequate diagnostic sample, which was obtained in 25 of the 27 aspirations (93%). CONCLUSIONS: The primary care internist can easily provide quality and timely small joint diagnostic aspiration when ultrasound is used to identify the location of the joint space.

Primary Care Management of Skin Abscesses Guided by Ultrasound.

BACKGROUND: Primary care providers often manage skin abscesses in the outpatient setting. Estimating the size and depth of an abscess, and distinguishing abscess from cellulitis by clinical examination can be challenging due to surrounding firm tissue induration. Definitive treatment of abscess requires incision and drainage, and the approach chosen may be altered by abscess size, depth, and surrounding neurovascular structures. METHODS: For 31 consecutive patients seen in the primary care outpatient clinic, we prospectively compared the estimated size of skin abscesses by clinical examination with that determined by ultrasound. Prior to incision and drainage, a limited point-of-care ultrasound examination was performed and the abscess dimensions were measured, the depth was determined, and adjacent vascular structures were noted. Based on ultrasound findings, physicians reported whether the decision to perform the procedure or the techniques used to perform the procedure were altered by the scan. RESULTS: The clinical examination was inaccurate for size estimation by >0.5 cm in 16 of 31 patients (52%). Ultrasound examination changed the physician decision of whether or not incision and drainage should be performed in 7 patients (23%) and altered the technique/approach in an additional 10 patients (32%); thus, management was changed in 55% of cases. Physician confidence in performing the procedure was improved in 16 cases (52%). CONCLUSION: Outpatient procedural management of skin abscesses by primary care physicians was altered in more than half the cases by performing point-of-care ultrasound prior to incision and drainage.

Telemonitoring Blood Pressure by Secure Message on a Patient Portal: Use, Content, and Outcomes.

INTRODUCTION: Secure messages on a patient portal allow patients to asynchronously communicate with their healthcare teams. Patients can use this mode of communication to transmit data such as home blood pressure (BP) measurements. MATERIALS AND METHODS: In this retrospective study, we examined 52,373 secure messages for content related to home BP monitoring. Text searches of the messages were followed by manual message review to identify BP-related messages. Two physicians independently reviewed a sample of these messages and the provider responses. RESULTS: Of 19,545 total message users, there were 4,412 message users with a diagnosis of hypertension and 365 who sent BP-related messages. Of the 52,373 secure messages, 624 messages (1.2%) contained information about home BP. Providers responded to messages with a change in medication dose or a prescription in 17%. When new medications were recommended, providers needed more pharmacy information in 53%. Messages contained a concern about high BP in 27% and concern about low BP in 8.5%. BP data in patient messages only attained American Heart Association-endorsed measurement criteria in 7% of messages. CONCLUSIONS: Patient-generated secure messages with BP data often result in message responses from providers for a BP medication dose change or a new prescription. Despite its increasing use, BP management by secure message has significant limitations and might be better served by BP virtual visits (e-visits) containing specific data requirements such as an average BP value from at least 12 readings and a preferred pharmacy for a prescription.

Cost-effectiveness of a quality improvement programme to reduce central line-associated bloodstream infections in intensive care units in the USA.

OBJECTIVE: To assess the cost-effectiveness of a multifaceted quality improvement programme focused on reducing central line-associated bloodstream infections in intensive care units. DESIGN: Cost-effectiveness analysis using a decision tree model to compare programme to non-programme intensive care units. SETTING: USA. POPULATION: Adult patients in the intensive care unit. COSTS: Economic costs of the programme and of central line-associated bloodstream infections were estimated from the perspective of the hospital and presented in 2013 US dollars. MAIN OUTCOME MEASURES: Central line-associated bloodstream infections prevented, deaths averted due to central line-associated bloodstream infections prevented, and incremental cost-effectiveness ratios. Probabilistic sensitivity analysis was performed. RESULTS: Compared with current practice, the programme is strongly dominant and reduces bloodstream infections and deaths at no additional cost. The probabilistic sensitivity analysis showed that there was an almost 80% probability that the programme reduces bloodstream infections and the infections' economic costs to hospitals. The opportunity cost of a bloodstream infection to a hospital was the most important model parameter in these analyses. CONCLUSIONS: This multifaceted quality improvement programme, as it is currently implemented by hospitals on an increasingly large scale in the USA, likely reduces the economic costs of central line-associated bloodstream infections for US hospitals. Awareness among hospitals about the programme's benefits should enhance implementation. The programme's implementation has the potential to substantially reduce morbidity, mortality and economic costs associated with central line-associated bloodstream infections.

Telemedicine barriers associated with regional quality measures.

Telemedicine practitioners are familiar with multiple barriers to delivering care at a distance. Licensing and reimbursement barriers are well known and are being addressed at national and state levels by the American Telemedicine Association. Another telemedicine barrier comes in the form of quality measures for diabetes. Minnesota medical practices are currently being compared on the proportion of their patients with diabetes who have attained goals for blood pressure, low-density lipoprotein cholesterol, and hemoglobin A1C. The quality measure for blood pressure specifically excludes measurements taken by the patient, thus precluding blood pressure telemonitoring as a way to meet the blood pressure goal. To counter this barrier, advocacy in telemedicine is needed so that telemonitoring as a data collection tool is included in quality measures.

Should you search the Internet for information about your acute symptom?

OBJECTIVE: To determine if symptom-related Web sites give sufficient information for users to seek urgent care when warranted. MATERIALS AND METHODS: We reviewed 120 Web sites (15 sites for each of eight acute symptoms). Symptom-related sites were identified with Google, Yahoo!®, and Bing™ searches and focused on potentially hazardous symptoms such as chest pain, shortness of breath, abdominal pain, and syncope. We reviewed each symptom-related site for the presence of critical symptom indicators (key symptom characteristics and associated factors) that triage the user to urgent care. RESULTS: Of the 120 sites reviewed, 41 (33%) contained no critical symptom indicators. No site contained a complete set of critical symptom indicators. Overall, out of the 1,020 total critical symptoms searched for in the sites, we only found 329 (32%). When present, critical symptom indicators were found on the top half of the first page of the site in only 34%. Specific recommendations for further care were absent in 42% of the cases where critical symptom indicators were identified. CONCLUSIONS: Symptom-related sites ranked highly by major search engines lack much of the information needed to make a decision about whether a symptom needs urgent attention. When present, this information is usually not located where users can rapidly access it and often lacks prescriptive guidance for users to seek care. Until more sites contain at least minimal triage advice, relying on an Internet search to help determine the urgency of a symptom could be risky.

Late-onset pediatric glaucoma associated with cutis marmorata telangiectatica congenita managed with Molteno implant surgery: case report and review of the literature.

Cutis marmorata telangiectatica congenita (CMTC) is characterized by the appearance of telangiectasia, phlebectasia, and a persistent reticular pattern of subcutaneous vasculature at or soon after birth. Up to 90% of cases are associated with systemic abnormalities, which include body asymmetry, cutaneous atrophy, neurological abnormalities, and vascular anomalies (nevus flammeus, Sturge-Weber syndrome, Klippel-Trenaunay syndrome, and capillary and cavernous hemangiomas). Glaucoma is the most commonly reported ocular association of CMTC, usually presenting in infancy. We report a case of CMTC associated with the previously unreported onset of glaucoma in mid-childhood that was managed by glaucoma drainage implant surgery and review the literature on glaucoma associated with this condition.

Building the business case for clinical quality.

Following are key findings of VHA Inc.'s Transformation of the ICU collaborative: Instead of improving patient outcomes, focusing too much on reducing costs as a performance improvement strategy only lays the groundwork for increased quality problems and higher costs. Improving quality can improve the bottom line, as long as there is patient demand. As a type, hospitals are organizations that characteristically have high fixed costs. The more customers such organizations can serve with the same investment, the greater their profits.

Vital signs: taking the pulse of your managed care contract performance.

Three essential baseline measures of managed care performance that should be reported on a regular basis are: Overall profitability of the organization's managed care portfolio. Payer mix and profitability. Performance of major managed care contracts.