Key challenges in prehospital and emergency care in Indonesia and Malaysia: a survey of frontline clinicians.

Rapid economic growth in Indonesia and Malaysia has widened the gap in emergency care supply and demand, intensifying challenges. Our study, from August to November 2022, assesses current diverse challenges in both countries' emergency care systems from frontline staff perspectives. The online survey involved emergency department (ED) personnel from 11 hospitals in Indonesia and Malaysia, drawing from an existing network. The survey collected data on respondents' characteristics, factors affecting prehospital and ED care quality, missing clinical information, and factors influencing patients' ED stay duration. With 83 respondents from Indonesia and 109 from Malaysia, the study identified common challenges. In both countries, inadequate clinical information from ambulances posed a primary challenge in prehospital care quality, while crowdedness during night shifts affected ED care quality. Frequent gaps in essential clinical information, such as family and medication history, were observed. Prolonged ED stays were associated with diagnostic studies and their turnaround time. This study offers insights into shared challenges in Indonesia and Malaysia's emergency care systems. Our findings stress recognizing common and country-specific challenges for enhanced emergency care quality in Southeast Asia, supporting tailored interventions.

Quality of neonatal health care in comprehensive specialized hospitals, Amhara Region, Ethiopia: a retrospective study with neonatal death audit.

BACKGROUND: Neonatal health is one of the targets for the sustainable development goals (SDGs) that aim to reduce neonatal mortality to at least as low as 12 per 1 000 live births in 2030. However, the world is not on track to achieve this target. The problem has worsened in many low-income countries, including Ethiopia, due to a fragile health system, as well as health crises such as the COVID-19 pandemic, conflict, food insecurity and climate change. According to the Mini Ethiopian Demographic Health Survey, neonatal mortality is unacceptably high in Ethiopia in general, and in Amhara region in particular. Despite these facts, there is a paucity of information on the quality of neonatal health service provision in comprehensive specialized hospitals in Amhara region. Therefore, this study is aimed at assessing the quality of neonatal health services in terms of outcome (neonatal mortality) and its causes in comprehensive specialized hospitals in Amhara region. METHODS: A multi-center retrospective study was conducted (from September 1-30/2022) on 315 neonates in four comprehensive hospitals with chart review. Data were collected through death audit with standardized neonatal death audit tool. Data were entered into Epi-data 3.1 and exported to SPSS 20 for analysis. Descriptive analysis was used to describe and summarize the data in an informative manner. RESULTS: From 315 neonatal deaths, about two-thirds, 205 (65.1%), were from rural areas. Nearly half, 151 (48%), of the mothers had complications and delivered outside a health facility. About 36 (11.4%), 45 (14.3%), and 21 (6.7%) neonates' mothers had 1st, 2nd, and 3rd delays, respectively. About 59 (19%) of mothers had membrane rupture before the onset of labor and 23 (7.3%) had meconium-stained liquor. Almost three-fourths, 226 (71.7%), of the deaths were low birth weight (< 2500 gram). About 25 (8%) of neonates had congenital anomalies, 65% of them had fast breathing and 54.6% were preterm. CONCLUSION: Higher proportions of neonatal deaths were observed among neonates with rural residence, low birth weight, mothers' complications and neonates admitted for fast breathing. Histories of abortion, complications, congenital anomalies, and the 3 delays contributed to neonatal deaths.

Segregation by Payer in Obstetrics and Gynecology Residency Ambulatory Care Sites.

Importance: Many teaching hospitals in the US segregate patients by insurance status, with resident clinics primarily composed of publicly insured or uninsured patients and faculty practices seeing privately insured patients. The prevalence of this model in obstetrics and gynecology residencies is unknown. Objectives: To examine the prevalence of payer-based segregation in obstetrics and gynecology residency ambulatory care sites nationally and to compare residents' and program directors' perceptions of differences in quality of care between payer-segregated and integrated sites. Design, Setting, and Participants: This national survey study included all 6060 obstetrics and gynecology residents and 293 obstetrics and gynecology residency program directors in the US as of January 2023. The proportion of program directors reporting payer segregation was calculated to characterize the national prevalence of this model in obstetrics and gynecology. Perceived differences in care quality were compared between residents and program directors at payer-segregated sites. Main Outcome and Measures: The primary measure was prevalence of payer-based segregation in obstetrics and gynecology residency programs in the US as reported by residency program directors. The secondary measure was resident and program director perceptions of care quality in these ambulatory care settings. Before study initiation, the study hypothesis was that residents and program directors at ambulatory sites with payer-based segregation would report more disparity in perceived health care quality between resident and faculty practices compared with those from integrated sites. Results: A total of 251 residency program directors (response rate, 85.7%) and 3471 residents (response rate, 57.3%) were included in the study. Resident respondent demographics reflected demographics of obstetrics and gynecology residents nationally in terms of racial and ethnic distribution (6 [0.2%] American Indian or Alaska Native; 425 [13.0%] Asian; 239 [7.3%] Black or African American; 290 [8.9%] Hispanic, Latinx, or Spanish; 7 [0.2%] Native Hawaiian or Other Pacific Islander; 2052 [62.7%] non-Hispanic White; 49 [1.5%] multiracial; 56 [1.7%] other [any race not listed]; and 137 [4.2%] preferred not to say) and geographic distribution (regional prevalence of payer-based segregation: 36 of 53 [67.9%] in the Northeast, 35 of 44 [79.5%] in the Midwest, 43 of 67 [64.2%] in the South, and 13 of 22 [59.1%] in the West), with 2837 respondents (86.9%) identifying as female. Among program directors, 127 (68.3%) reported payer-based segregation in ambulatory care. University programs were more likely to report payer-based segregation compared with community, hybrid, and military programs (63 of 85 [74.1%] vs 31 of 46 [67.4%], 32 of 51 [62.7%], and 0, respectively; P = .04). Residents at payer-segregated programs were less likely than their counterparts at integrated programs to report equal or higher care quality from residents compared with faculty (1662 [68.7%] vs 692 [81.6%] at segregated and integrated programs, respectively; P < .001). Conclusions and Relevance: In this survey study of residents and residency program directors, payer-based segregation was prevalent in obstetrics and gynecology residency programs, particularly at university programs. These findings reveal an opportunity for structural reform to promote more equitable care in residency training programs.

Electronic Health Record Nudges and Health Care Quality and Outcomes in Primary Care: A Systematic Review.

Importance: Nudges have been increasingly studied as a tool for facilitating behavior change and may represent a novel way to modify the electronic health record (EHR) to encourage evidence-based care. Objective: To evaluate the association between EHR nudges and health care outcomes in primary care settings and describe implementation facilitators and barriers. Evidence Review: On June 9, 2023, an electronic search was performed in PubMed, Embase, PsycINFO, CINAHL, and Web of Science for all articles about clinician-facing EHR nudges. After reviewing titles, abstracts, and full texts, the present review was restricted to articles that used a randomized clinical trial (RCT) design, focused on primary care settings, and evaluated the association between EHR nudges and health care quality and patient outcome measures. Two reviewers abstracted the following elements: country, targeted clinician types, medical conditions studied, length of evaluation period, study design, sample size, intervention conditions, nudge mechanisms, implementation facilitators and barriers encountered, and major findings. The findings were qualitatively reported by type of health care quality and patient outcome and type of primary care condition targeted. The Risk of Bias 2.0 tool was adapted to evaluate the studies based on RCT design (cluster, parallel, crossover). Studies were scored from 0 to 5 points, with higher scores indicating lower risk of bias. Findings: Fifty-four studies met the inclusion criteria. Overall, most studies (79.6%) were assessed to have a moderate risk of bias. Most or all descriptive (eg, documentation patterns) (30 of 38) or patient-centeredness measures (4 of 4) had positive associations with EHR nudges. As for other measures of health care quality and patient outcomes, few had positive associations between EHR nudges and patient safety (4 of 12), effectiveness (19 of 48), efficiency (0 of 4), patient-reported outcomes (0 of 3), patient adherence (1 of 2), or clinical outcome measures (1 of 7). Conclusions and Relevance: This systematic review found low- and moderate-quality evidence that suggested that EHR nudges were associated with improved descriptive measures (eg, documentation patterns). Meanwhile, it was unclear whether EHR nudges were associated with improvements in other areas of health care quality, such as effectiveness and patient safety outcomes. Future research is needed using longer evaluation periods, a broader range of primary care conditions, and in deimplementation contexts.

A theoretical framework for linking hospitals longitudinally: demonstrated using German Hospital Quality Reports 2016-2020.

BACKGROUND: In longitudinal health services research, hospital identification using an ID code, often supplemented with several additional variables, lacks clarity regarding representativeness and variable influence. This study presents an operational method for hospital identity delimitation and a novel longitudinal identification approach, demonstrated using a case study. METHODS: The conceptualisation considers hospitals as evolving entities, identifying "similar enough" pairs across two time points using an automated similarity matrix. This method comprises key variable selection, similarity scoring, and tolerance threshold definition, tailored to data source characteristics and clinical relevance. This linking method is tested by applying the identification of minimum caseload requirements-related German hospitals, utilizing German Hospital Quality Reports (GHQR) 2016-2020. RESULTS: The method achieved a success rate (min: 97.9% - max: 100%, mean: 99.9%) surpassing traditional hospital ID-code linkage (min: 91.5% - max: 98.8%, mean: 96.6%), with a remarkable 99% reduction in manual work through automation. CONCLUSIONS: This method, rooted in a comprehensive understanding of hospital identities, offers an operational, automated, and customisable process serving diverse clinical topics. This approach has the advantage of simultaneously considering multiple variables and systematically observing temporal changes in hospitals. It also enhances the precision and efficiency of longitudinal hospital identification in health services research.

Moderating role of relationships between workloads, job burnout, turnover intention, and healthcare quality among nurses.

BACKGROUND: In Jordan, nurses consider a primary providers of direct patient care, and play a multifaceted role in ensuring healthcare quality. The study aimed to examines the moderating effect of job satisfaction in the relationship between workload and healthcare quality, job burnout and healthcare quality, and turnover intention and healthcare quality. METHODS: A cross-sectional research approach was adopted among 311 from Registered Nurses (RN) across Jordanian hospitals. Job satisfaction, workload scale and job burnout scale were shared between March and April 2023. RESULTS: The overall findings indicate that workload, job burnout, and turnover intention are negatively and significantly related to healthcare quality, and that job satisfaction moderates the relationship between workload and healthcare quality, job burnout and healthcare quality, and turnover intention and healthcare quality. These findings have broad implications for healthcare organizations, emphasizing the pivotal role of job satisfaction in mitigating the negative effects of workload, burnout, and turnover intentions among nurses. CONSULSION: Strategies to enhance job satisfaction, such as reducing work-related stress and fostering supportive work environments, should be prioritized by healthcare policymakers and institutions to ensure the delivery of high-quality patient care.

Resource Use and Care Quality Differences Among Medicare Beneficiaries Undergoing Chemotherapy.

Importance: Medicare Advantage (MA) has grown significantly over the last decade; however, MA's performance for patients with serious conditions, such as cancer, remains unclear. Objective: To compare resource use and care quality between MA and traditional Medicare (TM) beneficiaries undergoing cancer chemotherapy. Design, Setting, and Participants: This cohort study used TM claims and MA encounter records from January 2015 to December 2019. Participants were MA and TM beneficiaries who initiated cancer chemotherapy between January 2016 and December 2019. Inverse probability of treatment weighting balanced characteristics between MA and TM beneficiaries, and regression estimation was used. The analysis was conducted between August 2023 and May 2024. Exposure: Chemotherapy initiation after a 1-year washout period. Main Outcomes and Measures: Resource use and care quality were measured during a 6-month period following chemotherapy initiation. Resource use was measured using standardized prices for services in both MA and TM, covering hospital inpatient services, outpatient care, Part D drugs, and hospice services. Chemotherapy utilization was examined for Part B chemotherapy, Part B supportive drugs, and Part D chemotherapy. Quality measures included chemotherapy-related emergency department (ED) visits and hospitalizations, avoidable ED visits, preventable hospitalizations during the 6-month episode, and survival days up to 18 months from chemotherapy initiation. Results: The study comprised 96 501 MA enrollees contributing to 98 872 episodes (mean [SD] age, 72.9 [7.6] years; 55 859 [56.5%] female; 7371 [7.5%] Hispanic, 14 778 [14.9%] non-Hispanic Black, and 75 130 [75.0%] non-Hispanic White participants) and 206 274 TM beneficiaries, contributing 212 969 episodes (mean [SD] age, 72.7 [8.3] years; 121 263 [56.9%] female; 8356 [3.9%] Hispanic, 16 693 [7.8%] non-Hispanic Black, and 182 228 [85.6%] non-Hispanic White participants). Adjusted total resource use per enrollee during the 6-month episode was $8718 (95% CI, $8343 to $9094) lower in MA than TM ($62 599 vs $71 317). Part B chemotherapy resource use accounted for most of the difference in total resource use, with MA enrollees having $5032 (95% CI, $4772 to $5293) lower use than TM beneficiaries. Lower resource use for Part B chemotherapy in MA was associated with both fewer chemotherapy visits (-1.06 visits; 95% CI, -1.10 to -1.02 visits) and less expensive chemotherapy per visit (-$277; 95% CI, -$275 to -$179). Findings on quality were mixed, but importantly, survival did not differ between MA and TM patients who initiated chemotherapy. Conclusions and Relevance: In this cohort study of Medicare beneficiaries with cancer undergoing chemotherapy, MA enrollment was associated with lower resource use but not shorter survival.

Rural-Urban Disparities in Hospital Services and Outcomes for Children With Medical Complexity.

Importance: Limited availability of inpatient pediatric services in rural regions has raised concerns about access, safety, and quality of hospital-based care for children. This may be particularly important for children with medical complexity (CMC). Objectives: To describe differences in the availability of pediatric services at acute care hospitals where rural- and urban-residing CMC presented for hospitalization; identify rural-urban disparities in health care quality and in-hospital mortality; and determine whether the availability of pediatric services at index hospitals or the experience of interfacility transfer modified rural-urban differences in outcomes. Design, Setting, and Participants: This retrospective cohort study examined all-payer claims data from Colorado, Massachusetts, and New Hampshire from 2012 to 2017. Analysis was conducted from May 2023 to July 2024. Participants included CMC younger than 18 years residing in these states and hospitalized during the study period. Exposures: Rural or urban residence was determined using Rural-Urban Commuting Area codes. Hospitals were categorized as children's hospitals or general hospitals with comprehensive, limited, or no dedicated pediatric services using American Hospital Association survey data. Interfacility transfers between index and definitive care hospitals were identified using health care claims. Main Outcomes and Measures: In-hospital mortality, all-cause 30-day readmission, medical-surgical safety events, and surgical safety events were operationalized using Agency for Healthcare Research and Quality measure specifications. Results: Among 36 943 CMC who experienced 79 906 hospitalizations, 16 525 (44.7%) were female, 26 034 (70.5%) were Medicaid-insured, and 34 008 (92.1%) were urban-residing. Rural-residing CMC were 6.55 times more likely to present to hospitals without dedicated pediatric services (rate ratio [RR], 6.55 [95% CI, 5.86-7.33]) and 2.03 times more likely to present to hospitals without pediatric beds (RR, 2.03 [95% CI, 1.88-2.21]) than urban-residing CMC, with no significant differences in interfacility transfer rates. In unadjusted analysis, rural-residing CMC had a 44% increased risk of in-hospital mortality (RR, 1.44 [95% CI, 1.03-2.02]) with no significant differences in other outcomes. Adjusting for clinical characteristics, the difference in in-hospital mortality was no longer significant. Index hospital type was not a significant modifier of observed rural-urban outcomes, but interfacility transfer was a significant modifier of rural-urban differences in surgical safety events. Conclusions and Relevance: In this cohort study, rural-residing CMC were significantly more likely to present to hospitals without dedicated pediatric services. These findings suggest that efforts are justified to ensure that all hospital types are prepared to care for CMC.

COVID-19 Mortality Disparities Among Socially Vulnerable Medicare Beneficiaries Associated With the Quality of Nurse Work Environments in U.S. Hospitals.

COVID-19 mortality disparities for socially vulnerable patients, including individuals facing higher levels of poverty, housing insecurity, and limited transportation, have been linked to the quality of hospitals where they received care. Few studies have examined the specific aspects of hospitals, such as nursing care quality, that may underlie disparate outcomes. Recent studies suggest that nursing resources in the pre-pandemic period were associated with mortality during the COVID-19 public health emergency. In this study, we examined the association between social vulnerability, the nurse work environment, and inpatient mortality among Medicare beneficiaries hospitalized with COVID-19. A cross-sectional analysis was conducted of linked survey data collected from nurses working in New York and Illinois, Medicare claims, American Hospital Association Annual Survey data, and the Social Vulnerability Index (SVI). Higher mortality rates were observed among patients in the highest quartile of social vulnerability compared to the lowest (6870 [25.8%] vs 5019 [19.1%]; P < .001). Using multivariable regression modeling, a statistically significant interaction was found between the highest SVI quartile and the nurse work environment (OR, 0.86; 95% CI, 0.76-0.98; P < .05), implying that the effect of a higher quality nurse work environment on mortality was decidedly greater for patients in the highest quartile (odds ratio = 0.86 × 0.94 = 0.80) compared to patients in the lowest quartile (OR, 0.94). Post-hoc analyses demonstrated that hundreds of COVID-19 related deaths among the most socially vulnerable patients may have been avoided if all hospitals had a high-quality nurse work environment. Strengthening the quality of nurse work environments may help to reduce health disparities and should be considered in public health emergency planning, specifically in hospitals serving socially vulnerable communities.

Physicians' training and patient education initiative to improve quality of care decision communication at the emergency department.

BACKGROUND: Discussions about care decisions, including code status documentation and advance care planning, are crucial components of patient-centred care. However, due to numerous barriers, these discussions are often avoided by both physicians and patients. As a result, these discussions often take place at the emergency department (ED). We aimed to improve the quality of care decision conversations in the internal medicine ED. METHODS: This pre-post intervention study was conducted at the internal medicine ED of a tertiary hospital in the Netherlands. Two interventions were implemented simultaneously: physician training and patient education. Physician training included an e-learning module and simulated patient sessions. Patients received a leaflet providing information about care decisions. Primary outcome was patient satisfaction with the care decision discussions, assessed using the Quality of Communication questionnaire. Secondary outcomes included the percentage of patients recalling a care decision discussion, initiator of the discussion, leaflet recall, leaflet evaluation, prior care decision discussions and perceived appropriate timing for discussions. RESULTS: 333 patients participated, 149 before and 184 after the interventions. Postintervention, there were significant improvements in patient-reported quality of care decision communication (p<0.001) and more patients recalled having care decision discussions (63.7% vs 45.9%, p=0.001). However, only 12% of patients recalled receiving the leaflet. CONCLUSIONS: Implementation of physician training and patient education significantly improved the quality of care decision conversations in our internal medicine ED. Despite low leaflet recall, the interventions demonstrated a notable impact on patient satisfaction with care decision discussions. Future research could explore alternative patient education methods and involve other healthcare professionals in initiating discussions. These findings underscore the importance of ongoing efforts to enhance communication in healthcare settings, particularly in emergency care.

Quality of birth care and risk factors of length of stay after birth: A machine learning approach.

AIM: Length of stay (LOS) is an outcome measure and is assumed to be related to quality. The objective of this study is to examine the quality of birth care and risk factors associated with LOS after birth. METHODS: A nationwide population-based Turkish Demographic and Health Survey (TDHS) was used for the year 2018. A total of 1849 women ages 15-49 were included. Explanatory factor analysis and machine learning predictors such as Random Forest, Support Vector Machine, Neural Network, k-Nearest Neighbor, and Naïve Bayes were used to identify the quality of birth care and risk factors associated with LOS after birth. RESULTS: As a result of the explanatory factor analysis, factor structures of quality of birth care, antenatal check-ups and supplements, and risk factors associated with birth were obtained using the Categorical Component Analysis method. The type of delivery, place of delivery, age, and type of place, which are under the quality of birth care, and risk factors associated with birth factors were found to be the variables that had the highest impact on LOS estimation. Random forest (Accuracy = 0.5789), support vector machine (radial) (Accuracy = 0.5766), and neural network (Accuracy = 0.5750) models outperformed, respectively. CONCLUSION: Type of delivery which is an indicator of quality of birth care is a strong predictor of LOS after birth according to the Random Forest model. We demonstrated that machine learning techniques offer precise LOS prediction after birth. Further studies assessing the effect of quality of birth care on predicting LOS at birth would be beneficial.

Intensive and critical care nurses patient safety, care quality, professional self-efficacy, and missed nursing care: Structural equation model analysis.

BACKGROUND: Globally, nurses' patient safety, care quality, and missed nursing care are well documented. However, there is a paucity of studies on the mediating roles of care quality and professional self-efficacy, particularly among intensive and critical care unit (ICCU) nurses in developing countries like the Philippines. AIM: To test a model of the interrelationships of patient safety, care quality, professional self-efficacy, and missed nursing care among ICCU nurses. METHODS: A cross-sectional, correlational design study was used. ICCU nurses (n = 335) were recruited via consecutive sampling from August to December 2023 and completed four validated self-report scales. Spearman Rho, structural equation modeling, mediation, and path analyses were utilized for data analysis. RESULTS: The emerging model demonstrated acceptable fit parameters. Patient safety positively influenced care quality (ß = .34, p = .002) and professional self-efficacy (ß = .18, p = .011), while negatively affecting missed nursing care (ß = -.34, p = .003). Care quality positively and negatively influenced professional self-efficacy (ß = .40, p = .003) and missed nursing care (ß = -.13, p = .003), respectively. Professional self-efficacy indirectly impacted missed nursing care (ß = -.32, p = .003). Care quality (ß = -.10, p = .003) and professional self-efficacy (ß = .13, p = .003) showed mediating effects between patient safety and missed nursing care. LINKING EVIDENCE TO ACTION: ICCU nurses' care quality and professional self-efficacy are essential mediating factors that can bolster patient safety practices, hence reducing missed nursing care. Therefore, healthcare organizations, nurse managers, and policymakers should cultivate care quality and self-efficacy by creating support programs and providing a positive practice environment. Nurses and nurse supervisors could directly observe missed nursing care in the ICCU to understand its underreported causes.

Nursing students' awareness, knowledge, and attitudes regarding telehealth and telenursing use for high-quality healthcare: A cross-sectional study.

BACKGROUND: Increasing technology use in healthcare has led to a focus on improving aspects of telehealth delivery to facilitate healthcare. Thus, students' understanding of the importance of telehealth and telenursing must be improved, as this plays a crucial role in shaping the future of healthcare. This study aimed to examine nursing students' awareness, knowledge, and attitudes regarding telehealth and telenursing use for high-quality healthcare. METHODS: A cross-sectional study was conducted on a convenience sample of 204 nursing students attending a public university in Saudi Arabia. An online questionnaire, supplemented by additional instruments, was used for data collection. The required bivariate and multivariate analyses were used to analyze the collected data. RESULTS: The study revealed that nursing students exhibited moderately high levels of awareness, knowledge, and attitudes regarding technology use for high-quality healthcare. Significant differences in the mean frequencies of internet use and knowledge (p < .05) and technology proficiency and knowledge (p < .05) were reported. The Pearson coefficient correlation test demonstrated that awareness was associated with knowledge (r = 0.350, p < .001), attitude (r = 0.660, p < .001), and years of technology use (r = -0.157, p = .025). Furthermore, attitude was significantly associated with knowledge (r = 0.295, p < .001) and years of technology use (r = -0.150, p = .032). In the regression, the awareness, knowledge, and attitude models were all significant (p < .05). CONCLUSIONS: The study's findings emphasize the need for targeted interventions to enhance nursing students' technological proficiency and awareness of telenursing. The predictive relationships among awareness, knowledge, and attitude also emphasize the need for a comprehensive and integrated educational approach. Future qualitative research studies should explore nursing students' perceptions of telenursing and how this could lead to high-quality healthcare.

Digital Maturity as a Predictor of Quality and Safety Outcomes in US Hospitals: Cross-Sectional Observational Study.

BACKGROUND: This study demonstrates that digital maturity contributes to strengthened quality and safety performance outcomes in US hospitals. Advanced digital maturity is associated with more digitally enabled work environments with automated flow of data across information systems to enable clinicians and leaders to track quality and safety outcomes. This research illustrates that an advanced digitally enabled workforce is associated with strong safety leadership and culture and better patient health and safety outcomes. OBJECTIVE: This study aimed to examine the relationship between digital maturity and quality and safety outcomes in US hospitals. METHODS: The data sources were hospital safety letter grades as well as quality and safety scores on a continuous scale published by The Leapfrog Group. We used the digital maturity level (measured using the Electronic Medical Record Assessment Model [EMRAM]) of 1026 US hospitals. This was a cross-sectional, observational study. Logistic, linear, and Tweedie regression analyses were used to explore the relationships among The Leapfrog Group's Hospital Safety Grades, individual Leapfrog safety scores, and digital maturity levels classified as advanced or fully developed digital maturity (EMRAM levels 6 and 7) or underdeveloped maturity (EMRAM level 0). Digital maturity was a predictor while controlling for hospital characteristics including teaching status, urban or rural location, hospital size measured by number of beds, whether the hospital was a referral center, and type of hospital ownership as confounding variables. Hospitals were divided into the following 2 groups to compare safety and quality outcomes: hospitals that were digitally advanced and hospitals with underdeveloped digital maturity. Data from The Leapfrog Group's Hospital Safety Grades report published in spring 2019 were matched to the hospitals with completed EMRAM assessments in 2019. Hospital characteristics such as number of hospital beds were obtained from the CMS database. RESULTS: The results revealed that the odds of achieving a higher Leapfrog Group Hospital Safety Grade was statistically significantly higher, by 3.25 times, for hospitals with advanced digital maturity (EMRAM maturity of 6 or 7; odds ratio 3.25, 95% CI 2.33-4.55). CONCLUSIONS: Hospitals with advanced digital maturity had statistically significantly reduced infection rates, reduced adverse events, and improved surgical safety outcomes. The study findings suggest a significant difference in quality and safety outcomes among hospitals with advanced digital maturity compared with hospitals with underdeveloped digital maturity.

Social disparities in access and quality of consultation in outpatient care in Germany.

BACKGROUND: Overall, research on social determinants of access and quality of outpatient care in Germany is scarce. Therefore, social disparities (according to sex, age, income, migration background, and health insurance) in perceived access and quality of consultation in outpatient care (primary care physicians and specialists) in Germany were explored in this study. METHODS: Analyses made use of a cross-sectional online survey. An adult population sample was randomly drawn from a panel which was recruited offline (N = 2,201). Perceived access was assessed by waiting time for an appointment (in days) and travel time to the practice (in minutes), while quality of consultation was measured by consultation time (in minutes) and quality of communication (scale of four items, Cronbach's Alpha 0.89). RESULTS: In terms of primary care, perceived access and quality of consultation was worse among women compared to men. Estimated consultation time was shorter among people with statutory health insurance compared to privately insured respondents. Regarding specialist care, people aged 60 years and older reported shorter waiting times and better quality of communication. Lower income groups reported lower quality of communication, while perceived access and quality of consultation was worse among respondents with a statutory health insurance. Variances explained by the social characteristics ranged between 1% and 4% for perceived access and between 3% and 7% for quality of consultation. CONCLUSION: We found social disparities in perceived access and quality of consultation in outpatient care in Germany. Such disparities in access may indicate structural discrimination, while disparities in quality of consultation may point to interpersonal discrimination in health care.

Assessing hypertension care quality in Brazil: gender, race, and socioeconomic intersection in public and private services, 2013 and 2019 national health surveys.

We conducted a cross-sectional study of hypertension care in public and private services, analyzing gender, color, and socioeconomic status. Using data from the 2013 (n = 60,202) and 2019 (n = 90,846) national health surveys, hypertension prevalence increased from 21.4 to 23.9%. Quality of care declined from 41.7 to 35.4%, particularly in public services, disproportionately affecting low-income Black women. Poisson regression estimated prevalence ratios (PRs), with the lowest adjusted PR for high-quality care among low-income Black women. These findings highlight persistent health inequalities and the urgent need for intersectoral policies to promote health equity.

Malaria community case management usage and quality of malaria care in a moderate Plasmodium falciparum burden region of Chadiza District, Zambia.

BACKGROUND: Malaria community case management (CCM) can improve timely access to healthcare, and CCM programmes in sub-Saharan Africa are expanding from serving children under 5 years (CU5) only to all ages. This report characterizes malaria case management in the setting of an age-expanded CCM programme in Chadiza District, Zambia. METHODS: Thirty-three households in each of 73 eligible communities were randomly selected to participate in a household survey preceding a trial of proactive CCM (NCT04839900). All household members were asked about fever in the prior two weeks and received a malaria rapid diagnostic test (RDT); those reporting fever were asked about healthcare received. Weighted population estimates were calculated and mixed effects regression was used to assess factors associated with malaria care seeking. RESULTS: Among 11,030 (98.6%) participants with RDT results (2,357 households), parasite prevalence was 19.1% by RDT; school-aged children (SAC, 5-14 years) had the highest prevalence (28.8%). Prior fever was reported by 12.4% of CU5, 7.5% of SAC, and 7.2% of individuals ≥ 15 years. Among those with prior fever, 34.0% of CU5, 56.0% of SAC, and 22.6% of individuals ≥ 15 years had a positive survey RDT and 73.7% of CU5, 66.5% of SAC, and 56.3% of individuals ≥ 15 years reported seeking treatment; 76.7% across all ages visited a CHW as part of care. Nearly 90% (87.8%) of people who visited a CHW reported a blood test compared with 73.5% seen only at a health facility and/or pharmacy (p < 0.001). Reported malaria treatment was similar by provider, and 85.9% of those with a reported positive malaria test reported getting malaria treatment; 66.9% of the subset with prior fever and a positive survey RDT reported malaria treatment. Age under 5 years, monthly or more frequent CHW home visits, and greater wealth were associated with increased odds of receiving healthcare. CONCLUSIONS: Chadiza District had high CHW coverage among individuals who sought care for fever. Further interventions are needed to increase the proportion of febrile individuals who receive healthcare. Strategies to decrease barriers to healthcare, such as CHW home visits, particularly targeting those of all ages in lower wealth strata, could maximize the benefits of CHW programmes.

Differences across race and ethnicity in the quality of antidepressant medication management.

OBJECTIVE: To illustrate the importance of a multidimensional view of disparities in quality of antidepressant medication management (AMM), as well as discriminating "within-facility" disparities from disparities that exist between facilities. DATA SOURCES AND STUDY SETTING: We used data from the Veterans Health Administration's (VA) Corporate Data Warehouse (CDW) which contains clinical and administrative data from VA facilities nationally. STUDY DESIGN: CDW data were used to measure five indicators of AMM quality, including the HEDIS Effective Acute-Phase and Effective Continuation-Phase measures. Mixed effects regression models were used to examine differences in quality indicators between racial/ethnic groups, controlling for other demographic and clinical factors. An adaptation of the Kitagawa-Blinder-Oaxaca (KBO) method was used to decompose mean differences in treatment quality between racial and ethnic groups into within- and between-facility effects. DATA EXTRACTION METHODS: Demographic, clinical, and health service utilization data were extracted for patients in fiscal year 2017 with a diagnosis of depression and a new start of an antidepressant medication. PRINCIPAL FINDINGS: The decomposition of the overall differences between White and Black patients on receiving an initial 90-day prescription (46.7% vs. 32.7%), Effective Acute-Phase (79.7% vs. 66.8%), and Effective Continuation-Phase (64.0% vs. 49.6%) HEDIS measures revealed that most of the overall effects were "within-facility," meaning that Black patients are less likely to meet these measures regardless of where they are treated. Although the overall magnitude of disparities between White and Hispanic patients on these three measures was very similar (46.7% vs. 32.7%; 79.7% vs. 69.2%; 64.0% vs. 53.6%), the differences were more attributable to Hispanic patients being treated in facilities with overall lower performance on these measures. CONCLUSIONS: Discriminating within- and between-facility disparities and taking a multidimensional view of quality are essential to informing efforts to address disparities in AMM quality.

Profiles of quality of outpatient care among individuals with mental disorders based on survey and administrative data.

RATIONALE: Though it is crucial to contribute to patient recovery through access, diversity, continuity and regularity of outpatient care, still today most of these are deemed nonoptimal. Identifying patient profiles based on outpatient service use and quality of care indicators might help formulate more personalized interventions and reduce adverse outcomes. AIMS AND OBJECTIVES: This study aimed to identify profiles of individuals with mental disorders (MDs) patterned after their outpatient care use and quality of care received, and to link those profiles to individual characteristics and subsequent outcomes. METHODS: A cohort of 5669 individuals with MDs was considered based on data from the 2013-2014 and 2015-2016 Canadian Community Health Survey, which were linked to administrative data from the Quebec health insurance registry. Latent class analysis generated profiles based on service use over the 12 months preceding each respondent's interview, and comparative analyses were used to associate profiles with sociodemographic and clinical characteristics, and health outcomes over the three following months. RESULTS: Four profiles were identified. Profile 1 (P-1) was labelled 'Low service use'; P-2 'Moderate general practitioner (GP) care and continuity and regularity of care'; P-3 'High GP care, continuity and regularity of care, and low psychiatrist care'; and P-4 'High psychiatrist care and regularity of care, and low GP care'. Profiles 3 and 4 (~50% of the cohort) were provided with better care, but showed worse outcomes, mainly acute care use due to more complex conditions and unmet needs. Profiles 1 and 2 had better outcomes as they showed fewer risk factors such as being younger and having better social conditions. CONCLUSION: Intensity, diversity and regularity of care were higher in profiles with more complex MDs, chronic physical illnesses, and worse perceived health conditions. Adapting specific interventions for each profile, such as assertive community treatment or intensive case management for Profile 4, is recommended.

Mental health care use and quality among Medicaid adults with serious mental illness receiving care at Federally Qualified Health Centers vs. other settings.

BACKGROUND: Federally Qualified Health Centers (FQHCs) are a critical source of care for medically underserved populations and often serve as medical homes for individuals with serious mental illness (SMI). Many FQHCs provide mental health services and could facilitate access to mental health treatment within and outside of FQHCs. This study compared mental health care utilization and acute care events for adult Medicaid enrollees with SMI who receive care at Federally Qualified Health Centers (FQHCs) vs. other settings. METHODS: This study used the 2015-2016 Massachusetts All-Payer Claims Database to examine outpatient mental health care and acute care events for 32,330 Medicaid adults, ages 18-64 and with major depressive, bipolar, or schizophrenia spectrum disorders (SSD), who resided in FQHC service areas and received care from FQHCs vs. other settings in 2015. Multivariable linear regressions assessed associations between receiving care at FQHCs and outpatient mental health visits, psychotropic medication fills, and acute care events in 2016. RESULTS: There were 8,887 (27.5%) adults in the study population (N = 32,330) who had at least one FQHC visit in 2015. Those who received care at FQHCs were more likely to have outpatient mental health visits (73.3% vs. 71.2%) and psychotropic medication fills (73.2% vs. 69.0%, both p < .05), including antidepressants among those with depressive disorders and antipsychotics among those with SSD. They were more likely to have ED visits (74.0% vs. 68.7%), but less likely to be hospitalized (27.8% vs. 31.9%, both p < .05). However, there was no significant difference in the likelihood of having an acute psychiatric hospitalization (9.5% vs. 9.8%, p = .35). CONCLUSIONS: Among Medicaid enrollees with SMIs who had access to care at FQHCs, those receiving care at FQHCs were more likely to have outpatient mental health visits and psychotropic medication fills, with lower rates of hospitalization, suggesting potentially improved quality of outpatient care. Higher ED visit rates among those receiving care at FQHCs warrant additional investigation.