Measuring Equity in Readmission as a Distinct Assessment of Hospital Performance.

Importance: Equity is an essential domain of health care quality. The Centers for Medicare & Medicaid Services (CMS) developed 2 Disparity Methods that together assess equity in clinical outcomes. Objectives: To define a measure of equitable readmissions; identify hospitals with equitable readmissions by insurance (dual eligible vs non-dual eligible) or patient race (Black vs White); and compare hospitals with and without equitable readmissions by hospital characteristics and performance on accountability measures (quality, cost, and value). Design, Setting, and Participants: Cross-sectional study of US hospitals eligible for the CMS Hospital-Wide Readmission measure using Medicare data from July 2018 through June 2019. Main Outcomes and Measures: We created a definition of equitable readmissions using CMS Disparity Methods, which evaluate hospitals on 2 methods: outcomes for populations at risk for disparities (across-hospital method); and disparities in care within hospitals' patient populations (within-a-single-hospital method). Exposures: Hospital patient demographics; hospital characteristics; and 3 measures of hospital performance-quality, cost, and value (quality relative to cost). Results: Of 4638 hospitals, 74% served a sufficient number of dual-eligible patients, and 42% served a sufficient number of Black patients to apply CMS Disparity Methods by insurance and race. Of eligible hospitals, 17% had equitable readmission rates by insurance and 30% by race. Hospitals with equitable readmissions by insurance or race cared for a lower percentage of Black patients (insurance, 1.9% [IQR, 0.2%-8.8%] vs 3.3% [IQR, 0.7%-10.8%], P < .01; race, 7.6% [IQR, 3.2%-16.6%] vs 9.3% [IQR, 4.0%-19.0%], P = .01), and differed from nonequitable hospitals in multiple domains (teaching status, geography, size; P < .01). In examining equity by insurance, hospitals with low costs were more likely to have equitable readmissions (odds ratio, 1.57 [95% CI, 1.38-1.77), and there was no relationship between quality and value, and equity. In examining equity by race, hospitals with high overall quality were more likely to have equitable readmissions (odds ratio, 1.14 [95% CI, 1.03-1.26]), and there was no relationship between cost and value, and equity. Conclusion and Relevance: A minority of hospitals achieved equitable readmissions. Notably, hospitals with equitable readmissions were characteristically different from those without. For example, hospitals with equitable readmissions served fewer Black patients, reinforcing the role of structural racism in hospital-level inequities. Implementation of an equitable readmission measure must consider unequal distribution of at-risk patients among hospitals.

Quality of hospital care and clinical outcomes: a comparison between the Lombardy Region and the Italian national data.

Background: Improving the quality and effectiveness of healthcare is a key priority in health policy. The emergence of the COVID-19 pandemic has exerted considerable pressure on hospital networks, requiring unprecedented reorganization and restructuring actions. This study analyzed data from the Italian National Outcomes Program to compare some volumes and outcomes of public and private accredited hospitals in the Lombardy Region with national data. Study design: Observational study. Methods: A thorough examination of hospital outcomes between 2019 and 2021 was conducted, considering 45 volume indicators and 48 process and outcome indicators, comparing Lombardy with other Italian regions and public versus private accredited hospitals. Results: In 2020, Italy and Lombardy experienced a considerable reduction in overall hospital admissions, with Lombardy showing a deeper decline (21.3% compared with 16.0% in Italy). In 2021, both experienced a partial recovery, especially marked in the Lombardy region (+7.3%, compared with national data). Focusing specifically on the private sector in Lombardy, a recovery of +9.3% in hospitalization was observed. In the analysis of clinical outcomes, Lombardy outperformed the national average for 63% of the indicators in 2020 and 83.3% in 2021. Conclusions: The study shows the continuing decline in volumes compared to 2019 (pre-COVID), the excellent performance of hospitals in Lombardy and a relevant contribution for the volumes and the quality of outcomes of private accredited hospitals.

Changes in Hospital Adverse Events and Patient Outcomes Associated With Private Equity Acquisition.

Importance: The effects of private equity acquisitions of US hospitals on the clinical quality of inpatient care and patient outcomes remain largely unknown. Objective: To examine changes in hospital-acquired adverse events and hospitalization outcomes associated with private equity acquisitions of US hospitals. Design, Setting, and Participants: Data from 100% Medicare Part A claims for 662 095 hospitalizations at 51 private equity-acquired hospitals were compared with data for 4 160 720 hospitalizations at 259 matched control hospitals (not acquired by private equity) for hospital stays between 2009 and 2019. An event study, difference-in-differences design was used to assess hospitalizations from 3 years before to 3 years after private equity acquisition using a linear model that was adjusted for patient and hospital attributes. Main Outcomes and Measures: Hospital-acquired adverse events (synonymous with hospital-acquired conditions; the individual conditions were defined by the US Centers for Medicare & Medicaid Services as falls, infections, and other adverse events), patient mix, and hospitalization outcomes (including mortality, discharge disposition, length of stay, and readmissions). Results: Hospital-acquired adverse events (or conditions) were observed within 10 091 hospitalizations. After private equity acquisition, Medicare beneficiaries admitted to private equity hospitals experienced a 25.4% increase in hospital-acquired conditions compared with those treated at control hospitals (4.6 [95% CI, 2.0-7.2] additional hospital-acquired conditions per 10 000 hospitalizations, P = .004). This increase in hospital-acquired conditions was driven by a 27.3% increase in falls (P = .02) and a 37.7% increase in central line-associated bloodstream infections (P = .04) at private equity hospitals, despite placing 16.2% fewer central lines. Surgical site infections doubled from 10.8 to 21.6 per 10 000 hospitalizations at private equity hospitals despite an 8.1% reduction in surgical volume; meanwhile, such infections decreased at control hospitals, though statistical precision of the between-group comparison was limited by the smaller sample size of surgical hospitalizations. Compared with Medicare beneficiaries treated at control hospitals, those treated at private equity hospitals were modestly younger, less likely to be dually eligible for Medicare and Medicaid, and more often transferred to other acute care hospitals after shorter lengths of stay. In-hospital mortality (n = 162 652 in the population or 3.4% on average) decreased slightly at private equity hospitals compared with the control hospitals; there was no differential change in mortality by 30 days after hospital discharge. Conclusions and Relevance: Private equity acquisition was associated with increased hospital-acquired adverse events, including falls and central line-associated bloodstream infections, along with a larger but less statistically precise increase in surgical site infections. Shifts in patient mix toward younger and fewer dually eligible beneficiaries admitted and increased transfers to other hospitals may explain the small decrease in in-hospital mortality at private equity hospitals relative to the control hospitals, which was no longer evident 30 days after discharge. These findings heighten concerns about the implications of private equity on health care delivery.

The Volume and Cost of Quality Metric Reporting.

Importance: US hospitals report data on many health care quality metrics to government and independent health care rating organizations, but the annual cost to acute care hospitals of measuring and reporting quality metric data, independent of resources spent on quality interventions, is not well known. Objective: To evaluate externally reported inpatient quality metrics for adult patients and estimate the cost of data collection and reporting, independent of quality-improvement efforts. Design, Setting, and Participants: Retrospective time-driven activity-based costing study at the Johns Hopkins Hospital (Baltimore, Maryland) with hospital personnel involved in quality metric reporting processes interviewed between January 1, 2019, and June 30, 2019, about quality reporting activities in the 2018 calendar year. Main Outcomes and Measures: Outcomes included the number of metrics, annual person-hours per metric type, and annual personnel cost per metric type. Results: A total of 162 unique metrics were identified, of which 96 (59.3%) were claims-based, 107 (66.0%) were outcome metrics, and 101 (62.3%) were related to patient safety. Preparing and reporting data for these metrics required an estimated 108 478 person-hours, with an estimated personnel cost of $5 038 218.28 (2022 USD) plus an additional $602 730.66 in vendor fees. Claims-based (96 metrics; $37 553.58 per metric per year) and chart-abstracted (26 metrics; $33 871.30 per metric per year) metrics used the most resources per metric, while electronic metrics consumed far less (4 metrics; $1901.58 per metric per year). Conclusions and Relevance: Significant resources are expended exclusively for quality reporting, and some methods of quality assessment are far more expensive than others. Claims-based metrics were unexpectedly found to be the most resource intensive of all metric types. Policy makers should consider reducing the number of metrics and shifting to electronic metrics, when possible, to optimize resources spent in the overall pursuit of higher quality.

Quality of Care and Clinical Outcomes for Patients With Heart Failure at Hospitals Caring for a High Proportion of Black Adults: Get With The Guidelines-Heart Failure Registry.

Importance: Black adults with heart failure (HF) disproportionately experience higher population-level mortality than White adults with HF. Whether quality of care for HF differs at hospitals with high proportions of Black patients compared with other hospitals is unknown. Objective: To compare quality and outcomes for patients with HF at hospitals with high proportions of Black patients vs other hospitals. Design, Setting, and Participants: Patients hospitalized for HF at Get With The Guidelines (GWTG) HF sites from January 1, 2016, through December 1, 2019. These data were analyzed from May 2022 through November 2022. Exposures: Hospitals caring for high proportions of Black patients. Main Outcomes and Measures: Quality of HF care based on 14 evidence-based measures, overall defect-free HF care, and 30-day readmissions and mortality in Medicare patients. Results: This study included 422 483 patients (224 270 male [53.1%] and 284 618 White [67.4%]) with a mean age of 73.0 years. Among 480 hospitals participating in GWTG-HF, 96 were classified as hospitals with high proportions of Black patients. Quality of care was similar between hospitals with high proportions of Black patients compared with other hospitals for 11 of 14 GWTG-HF measures, including use of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitors for left ventricle systolic dysfunction (high-proportion Black hospitals: 92.7% vs other hospitals: 92.4%; adjusted odds ratio [OR], 0.91; 95% CI, 0.65-1.27), evidence-based ß-blockers (94.7% vs 93.7%; OR, 1.02; 95% CI, 0.82-1.28), angiotensin receptor neprilysin inhibitors at discharge (14.3% vs 16.8%; OR, 0.74; 95% CI, 0.54-1.02), anticoagulation for atrial fibrillation/flutter (88.8% vs 87.5%; OR, 1.05; 95% CI, 0.76-1.45), and implantable cardioverter-defibrillator counseling/placement/prescription at discharge (70.9% vs 71.0%; OR, 0.75; 95% CI, 0.50-1.13). Patients at high-proportion Black hospitals were less likely to be discharged with a follow-up visit made within 7 days or less (70.4% vs 80.1%; OR, 0.68; 95% CI, 0.53-0.86), receive cardiac resynchronization device placement/prescription (50.6% vs 53.8%; OR, 0.63; 95% CI, 0.42-0.95), or an aldosterone antagonist (50.4% vs 53.5%; OR, 0.69; 95% CI, 0.50-0.97). Overall defect-free HF care was similar between both groups of hospitals (82.6% vs 83.4%; OR, 0.89; 95% CI, 0.67-1.19) and there were no significant within-hospital differences in quality for Black patients vs White patients. Among Medicare beneficiaries, the risk-adjusted hazard ratio (HR) for 30-day readmissions was higher at high-proportion Black vs other hospitals (HR, 1.14; 95% CI, 1.02-1.26), but similar for 30-day mortality (HR 0.92; 95% CI,0.84-1.02). Conclusions and Relevance: Quality of care for HF was similar across 11 of 14 measures at hospitals caring for high proportions of Black patients compared with other hospitals, as was overall defect-free HF care. There were no significant within-hospital differences in quality for Black patients vs White patients.

Patients satisfaction with dental service, school of dentistry, University of Costa Rica / Satisfacción de los usuarios del Servicio de Odontología, Universidad de Costa Rica

The objective of this research was to use the Dental Satisfaction Questionnaire to determine the level of patient's satisfaction who come to the School of Dentistry of the University of Costa Rica. The research was conducted with the entire population of patients who received dental care in the Undergraduate Student Clinics of the School of Dentistry between April and September 2021. A digital survey was generated with the questions of the DSQ and sociodemographic variables, which was sent by email. Descriptive statistics were performed to establish the absolute and relative frequency, as well as measures of central tendency and variability, according to the nature of the variables. The Kolmogorov-Smirnov test was used in the conformity assessment of the data for the normal distribution. The relationships between the scores obtained from the Dental Satisfaction Questionnaire and the sociodemographic variables were analyzed using the Mann-Whitney U Test and the Kruskal-Wallis Test. A response rate of 36% was obtained. 98.5% of the subjects were satisfied with the services received. There was a statistically significant difference between the frequency of visits and the dental satisfaction scale (p=0.001). The scoring by type of clinic with regards to access, pain management, cost and availability were statistically significant (p=0.001, p=0.014, p=0.001, p=0.001, respectively). The differences in the relationship between the age groups and access was significant (p=0.014); in addition to that between education level and cost (p=0.001). A large majority of patients who come to the services of the School of Dentistry UCR are satisfied with the service received.

El objetivo de esta investigación fue utilizar el cuestionario DSQ para determinar el nivel de satisfacción de los pacientes que acuden a la Facultad de Odontología de la UCR. La investigación se realizó con toda la población de pacientes que recibieron atención dental en las Clínicas de pregrado y grado de la Facultad de Odontología UCR entre abril y setiembre del 2021. Se generó una encuesta digital con las preguntas del cuestionario DSQ y variables sociodemográficas, la cual se envió por medio del correo electrónico. Se realizó estadística descriptiva estableciendo la frecuencia absoluta y relativa, así como medidas de tendencia central y variabilidad, según la naturaleza de las variables. La prueba de Kolmogorov-Smirnov fue utilizada en la evaluación de la conformidad de los datos para la distribución normal. Las relaciones entre las puntuaciones obtenidas del Cuestionario de Satisfacción Dental y las variables sociodemográficas se analizaron mediante las pruebas de Prueba U de Mann-Whitney y la Prueba de Kruskal-Wallis. Se obtuvo un índice de respuesta del 36%. El 98,5% de los sujetos estuvo satisfecho con los servicios recibidos. Hubo diferencia estadísticamente significativa entre la frecuencia de visitas y la escala de satisfacción dental (p=0,001). También hubo diferencia estadísticamente significativa entre las diferentes clínicas y el acceso, manejo del dolor, costo y disponibilidad (p=0,001, p=0,014, p=0,001, p=0,001, respectivamente). De igual forma, hubo diferencia significativa en los grupos de edad y el acceso (p=0,014) y entre el nivel educativo y el costo (p=0,001). Una gran mayoría de los pacientes que acuden a los servicios de la Facultad de Odontología UCR están satisfechos con el servicio recibido.

Organization and Performance of US Health Systems.

Importance: Health systems play a central role in the delivery of health care, but relatively little is known about these organizations and their performance. Objective: To (1) identify and describe health systems in the United States; (2) assess differences between physicians and hospitals in and outside of health systems; and (3) compare quality and cost of care delivered by physicians and hospitals in and outside of health systems. Evidence Review: Health systems were defined as groups of commonly owned or managed entities that included at least 1 general acute care hospital, 10 primary care physicians, and 50 total physicians located within a single hospital referral region. They were identified using Centers for Medicare & Medicaid Services administrative data, Internal Revenue Service filings, Medicare and commercial claims, and other data. Health systems were categorized as academic, public, large for-profit, large nonprofit, or other private systems. Quality of preventive care, chronic disease management, patient experience, low-value care, mortality, hospital readmissions, and spending were assessed for Medicare beneficiaries attributed to system and nonsystem physicians. Prices for physician and hospital services and total spending were assessed in 2018 commercial claims data. Outcomes were adjusted for patient characteristics and geographic area. Findings: A total of 580 health systems were identified and varied greatly in size. Systems accounted for 40% of physicians and 84% of general acute care hospital beds and delivered primary care to 41% of traditional Medicare beneficiaries. Academic and large nonprofit systems accounted for a majority of system physicians (80%) and system hospital beds (64%). System hospitals were larger than nonsystem hospitals (67% vs 23% with >100 beds), as were system physician practices (74% vs 12% with >100 physicians). Performance on measures of preventive care, clinical quality, and patient experience was modestly higher for health system physicians and hospitals than for nonsystem physicians and hospitals. Prices paid to health system physicians and hospitals were significantly higher than prices paid to nonsystem physicians and hospitals (12%-26% higher for physician services, 31% for hospital services). Adjusting for practice size attenuated health systems differences on quality measures, but price differences for small and medium practices remained large. Conclusions and Relevance: In 2018, health system physicians and hospitals delivered a large portion of medical services. Performance on clinical quality and patient experience measures was marginally better in systems but spending and prices were substantially higher. This was especially true for small practices. Small quality differentials combined with large price differentials suggests that health systems have not, on average, realized their potential for better care at equal or lower cost.

Efficiency of the Japanese Hospitalist System for Patients with Urinary Tract Infection: A Propensity-matched Analysis.

Objective The hospitalist system in the United States has been considered successful in terms of the quality of care and cost effectiveness. In Japan, however, its efficacy has not yet been extensively examined. This study examined the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population using treatment of urinary tract infection as an example. Methods We analyzed 271 patients whose most resource-consuming diagnosis at admission was urinary tract infection between April 2017 and March 2019. Propensity-matched analyses were performed to compare health care economics and the quality of care between the hospitalist system and the conventional system. Results In matched pairs, care by the hospitalist system was associated with a significantly shorter length of stay than that by the conventional system. The quality of care (oral antibiotics switch rate, rate of appropriate antibiotics change based on urine or blood culture results, detection rate of urinary tract infection etiology and the number of laboratory tests) was also considered to be favorably impacted by the hospitalist system. Although not statistically significant, hospital costs tended to be lower with the hospitalist system than with the conventional system. The mortality rate and 30-day readmission were also not significantly different between the groups. Conclusion The hospitalist system had a favorable impact on the quality of care and length of stay without increasing readmission in patients with urinary tract infection. This study is further evidence of the strong potential for the positive impact of an implemented hospitalist system in Japan.

Medicare beneficiaries with more comprehensive primary care physicians report better primary care.

OBJECTIVE: To examine whether primary care physician (PCP) comprehensiveness is associated with Medicare beneficiaries' overall rating of care from their PCP and staff. DATA SOURCES: We linked Medicare claims with survey data from Medicare beneficiaries attributed to Comprehensive Primary Care Plus (CPC+) physicians and practices. STUDY DESIGN: We performed regression analyses of the associations between two claims-based measures of PCP comprehensiveness in 2017 and beneficiaries' rating of care from their PCP and practice staff in 2018. DATA COLLECTION/EXTRACTION METHODS: The analytic sample included 6228 beneficiaries cared for by 3898 PCPs. Regressions controlled for beneficiary, physician, practice, and market characteristics. PRINCIPAL FINDINGS: Beneficiaries with more comprehensive PCPs rated care from their PCP and practice staff higher than did those with less comprehensive PCPs. For each comprehensiveness measure, beneficiaries whose PCP was in the 75th percentile were more likely than beneficiaries whose PCP was in the 25th percentile to rate their care highly (2 percentage point difference, p = 0.02). CONCLUSIONS: Medicare beneficiaries with more comprehensive PCPs rate overall care from their PCPs and staff higher than those with less comprehensive PCPs.

Satisfacción con la calidad de atención en pacientes en hemodiálisis de un hospital de Sonora / Satisfaction with quality of care in patients on hemodialysis in a hospital in Sonora

Introducción: la satisfacción con la calidad en la atención de enfermería por parte del paciente es el resultado de la relación profesional entre la enfermera y el paciente. Objetivo: evaluar la satisfacción con la calidad en la atención de enfermería de los pacientes de hemodiálisis de un hospital de especialidades en Sonora. Metodología: estudio cuantitativo, observacional, descriptivo, transversal y prospectivo, realizado mediante la aplicación del cuestionario SERVQHOS-E, que consta de 16 ítems y una encuesta de opinión y sirve para medir la satisfacción del paciente y la calidad percibida de la atención de enfermería. El análisis de datos se hizo con estadística descriptiva, frecuencias relativas y absolutas. Resultados: se estudiaron 146 pacientes. En cuanto a percepción de la calidad de la atención de enfermería, 99.3% estuvieron satisfechos y solo 0.7% estuvieron insatisfechos. En relación con la satisfacción global, el 100% se manifestaron satisfechos y 99.3% de los pacientes recomendaría el servicio. Conclusión: los pacientes con hemodiálisis de un hospital de especialidades en Sonora se encuentran satisfechos.

Introduction: Patient satisfaction with the quality of nursing care is the result of the professional relationship between nurse and patient. Objective: To assess patient satisfaction with hemodialysis as relates to the quality of nursing care in a specialty hospital in Sonora. Methodology: observational, descriptive, cross-sectional and prospective study, which was carried out using the SERVQHOS-E questionnaire, which consists of 16 items and one survey and measures the patient satisfaction and the perceived quality about nursing care. Data analysis was completed through descriptive statistics, relative and absolute frequencies. Results: 146 patients were studied. Concerning the perceived quality of nursing care, 99.3% were satisfied and only 0.7% reported dissatisfaction. Regarding global satisfaction, 100% of patients expressed satisfaction with their stay and 99.3% would recommend the services received to others. Conclusion: Hemodialysis patients at a specialty hospital in Sonora are satisfied.

Potential of Electronic Medical Record Data for National Quality Measurement.

National quality measurements with risk-adjusted provider comparison in health care nowadays usually require administrative or clinically measured data. However, both data sources have their limitations. Due to the digitalisation of institutions and the resulting switch to electronic medical records, the question arises as to whether these data can be made usable for risk-adjusted quality comparisons from both a content and a technical point of view. We found that most of the relevant information can be exported with little effort from the electronic medical records. In using this data source an even more sophisticated operationalization of the data of interest is needed.

Application of PDCA Process Management in Day Operation Ward and the Influence of Nursing Quality and Safety.

Objective: To survey the application of PDCA (plan, do, check, and action) process management in day operation ward and the influence of nursing quality and safety. Methods: The routine nursing management was carried out in our hospital from March 2019 to March 2020, which was set as the control group (N = 20), and the PDCA process management was implemented from March 2020 to March 2021 as the research group (N = 20). Twenty nurses and patients were selected as subjects in two periods of time. The nursing quality, the score of individual quality control examination in clinical department, the nursing quality of operating room, the incidence of adverse events and nursing errors, the number of problems existing in the quality management of nursing documents, and the score of nursing satisfaction were accessed. Results: In the comparison of nursing quality, the nursing safety, specialty quality, and nursing norms of the study group were higher compared to the control (P < 0.05). In terms of the scores of individual quality control examination in clinical departments, the scores of ward management, rescue, therapeutic articles, drug management, first-level nursing, nursing documents, and head nurses in the study group were greater compared to the control (P < 0.05). In terms of the operating room nursing quality score, the instrument management, instrument preparation, nurses' cooperation skills, disinfection and isolation quality, and the total score of the study group were above the control (P < 0.05). In terms of the incidence of operative adverse events and nursing errors, the incidence of nosocomial infection, iatrogenic injury, information check error, equipment failure, violation of operation regulations, ECG monitoring error, infusion operation error, and medication error in the study group was lower compared to the control (P < 0.05). According to the comparison of the number of problems existing in the quality management of nursing documents, the number of problems in temperature sheet, medical order, evaluation sheet, nursing record, and other nursing documents in the study group was lower than the control (P < 0.05). The scores of nursing communication, professional technology, nursing service attitude, nursing environment, and knowledge education in the study group were higher in contrast to the control (P < 0.05). Conclusion: The application of PDCA management can effectively enhance the nursing quality and safety of the day operation ward, further facilitate the quality of hospital nursing work, and improve patient satisfaction, which exert great potential, and application value in the management of day ward in the future.

"I just have to hope that this abortion should go well": Perceptions, fears, and experiences of abortion clients in Nigeria.

This qualitative study aimed to examine how abortion clients in Nigeria perceive abortion and explore the role their beliefs and fears play in their care-seeking experiences and interactions with providers. Abortion is severely legally restricted in Nigeria but remains common. We conducted in-depth interviews with 25 people who obtained abortion services through three distinct models of care. We coded interview transcripts and conducted thematic analysis. Clients perceived negative attitudes toward abortion in their communities, though clients' own beliefs were more nuanced. Clients recounted a range of fears, and nearly all mentioned worrying that they might die as a result of their abortion. Despite their concerns, clients relied on social networks and word-of-mouth recommendations to identify providers they perceived as trustworthy and safe. Kind and non-judgmental treatment, clear instructions, open communication, and reassurance of privacy and confidentiality by providers alleviated client fears and helped clients feel supported throughout their abortion process. Within restrictive contexts, the mobilization of information networks, provision of high-quality care through innovative models, and personalization of care to individual needs can assuage fears and contribute to reducing stigma and increasing access to safe abortion services.

Quality and Safety Outcomes of a Hospital Merger Following a Full Integration at a Safety Net Hospital.

Importance: Hospital consolidations have been shown not to improve quality on average. Objective: To assess a full-integration approach to hospital mergers based on quality metrics in a safety net hospital acquired by an urban academic health system. Design, Setting, and Participants: This quality improvement study analyzed outcomes for all nonpsychiatric, nonrehabilitation, non-newborn patients discharged between September 1, 2010, and August 31, 2019, at a US safety net hospital that was acquired by an urban academic health system in January 2016. Interrupted time series and statistical process control analyses were used to assess the main outcomes and measures. Data sources included the hospital's electronic health record, Centers for Medicare & Medicaid Services Hospital Compare, and nursing quality reports. Exposures: A full-integration approach to the merger that included: (1) early administrative and clinical leadership integration with the academic health system; (2) rapid transition to the academic health system electronic health record; (3) local ownership of quality metrics; (4) system-level goals with real-time actionable analytics through combined dashboards; and (5) implementation of value-based and other analytic-driven interventions. Main Outcomes and Measures: The primary outcome was in-hospital mortality. Secondary outcomes included 30-day readmission, patient experience, and hospital-acquired conditions. Results: The 122 348 patients in the premerger (September 2010 through August 2016) and the 58 904 patients in the postmerger (September 2016 through August 2019) periods had a mean (SD) age of 55.5 (22.0) years; the total sample of 181 252 patients included 112 191 women (61.9%), the payor mix was majority governmental (144 375 patients [79.7%]), and most admissions were emergent (121 469 patients [67.0%]). There was a 0.71% (95% CI, 0.57%-0.86%) absolute (27% relative) reduction in the crude mortality rate and 0.95% (95% CI, 0.83%-1.12%) absolute (33% relative) in the adjusted rate by the end of the 3-year intervention period. There was no significant improvement in readmission rates after accounting for baseline trends. There were fewer central line infections per 1000 catheter days, fewer catheter-associated urinary tract infections per 1000 discharges, and a higher likelihood of patients recommending the hospital or ranking it 9 or 10. Conclusions and Relevance: In this quality improvement study, a hospital merger with a full-integration approach to consolidation was found to be associated with improvement in quality outcomes.

Do empowered women receive better quality antenatal care in Pakistan? An analysis of demographic and health survey data.

INTRODUCTION: Quality antenatal care is a window of opportunity for improving maternal and neonatal outcomes. Numerous studies have shown a positive effect of women empowerment on improved coverage of maternal and reproductive health services, including antenatal care (ANC). However, there is scarce evidence on the association between women's empowerment and improved ANC services both in terms of coverage and quality. Addressing this gap, this paper examines the relationship between multi-dimensional measures of women empowerment on utilization of quality ANC (service coverage and consultation) in Pakistan. METHODS: We used Pakistan Demographic and Health Survey 2017-18 (PDHS) data which comprises of 6,602 currently married women aged between 15-49 years who had a live birth in the past five years preceding the survey. Our exposure variables were three-dimensional measures of women empowerment (social independence, decision making, and attitude towards domestic violence), and our outcome variables were quality of antenatal coverage [i.e. a composite binary measure based on skilled ANC (trained professional), timeliness (1st ANC visit during first trimester), sufficiency of ANC visits (4 or more)] and quality of ANC consultation (i.e. receiving at least 7 or more essential antenatal components out of 8). Data were analysed in Stata 16.0 software. Descriptive statistics were used to describe sample characteristics and binary logistic regression was employed to assess the association between empowerment and quality of antenatal care. RESULTS: We found that 41.4% of the women received quality ANC coverage and 30.6% received quality ANC consultations during pregnancy. After controlling for a number of socio-economic and demographic factors, all three measures of women's empowerment independently showed a positive relationship with both outcomes. Women with high autonomy (i.e. strongly opposed the notion of violence) in the domain of attitude to violence are 1.66 (95% CI 1.30-2.10) and 1.45 (95% CI 1.19-1.75) and times more likely to receive antenatal coverage and quality ANC consultations respectively, compared with women who ranked low on attitude to violence. Women who enjoy high social independence had 1.87 (95% CI 1.44-2.43) and 2.78 (95% CI 2.04-3.79) higher odds of quality antenatal coverage and consultations respectively, as compared with their counterparts. Similarly, women who had high autonomy in household decision making 1.98 (95% CI 1.60-2.44) and 1.56 (95% CI 2.17-1.91) were more likely to receive quality antenatal coverage and consultation respectively, as compared to women who possess low autonomy in household decision making. CONCLUSION: The quality of ANC coverage and consultation with service provider is considerably low in Pakistan. Women's empowerment related to social independence, gendered beliefs about violence, and decision-making have an independent positive association with the utilisation of quality antenatal care. Thus, efforts directed towards empowering women could be an effective strategy to improve utilisation of quality antenatal care in Pakistan.

Exploring association between place of delivery and newborn care with early-neonatal mortality in Bangladesh.

OBJECTIVE: Bangladesh achieved the fourth Millennium Development Goal well ahead of schedule, with a significant reduction in under-5 mortality between 1990 and 2015. However, the reduction in neonatal mortality has been stagnant in recent years. The purpose of this study is to explore the association between place of delivery and newborn care with early neonatal mortality (ENNM), which represents more than 80% of total neonatal mortality in Bangladesh. METHODS: In this study, 2014 Bangladesh Demographic and Health Survey data were used to assess early neonatal survival in children born in the three years preceding the survey. The roles of place of the delivery and newborn care in ENNM were examined using multivariable logistic regression models adjusted for clustering and relevant socio-economic, pregnancy, and newborn characteristics. RESULTS: Between 2012 and 2014, there were 4,624 deliveries in 17,863 sampled households, 39% of which were delivered at health facilities. The estimated early neonatal mortality rate during this period was 15 deaths per 1,000 live births. We found that newborns who had received at least 3 components of essential newborn care (ENC) were 56% less likely to die during the first seven days of their lives compared to their counterparts who received 0-2 components of ENC (aOR: 0.44; 95% CI: 0.24-0.81). In addition, newborns who had received any postnatal care (PNC) were 68% less likely to die in the early neonatal period than those who had not received any PNC (aOR: 0.32; 95% CI: 0.16-0.64). Facility delivery was not significantly associated with the risk of early newborn death in any of the models. CONCLUSION: Our study findings highlight the importance of newborn and postnatal care in preventing early neonatal deaths. Further, findings suggest that increasing the proportion of women who give birth in a healthcare facility is not sufficient to reduce ENNM by itself; to realize the theoretical potential of facility delivery to avert neonatal deaths, we must also ensure quality of care during delivery, guarantee all components of ENC, and provide high-quality early PNC. Therefore, sustained efforts to expand access to high-quality ENC and PNC are needed in health facilities, particularly in facilities serving low-income populations.

Comparing Postoperative Readmission Rates Between Veterans Receiving Total Knee Arthroplasty in the Veterans Health Administration Versus Community Care.

BACKGROUND: There are growing concerns that Veterans' increased use of Veterans Health Administration (VA)-purchased care in the community may lead to lower quality of care. OBJECTIVE: We compared rates of hospital readmissions following elective total knee arthroplasties (TKAs) that were either performed in VA or purchased by VA through community care (CC) at both the national and facility levels. METHODS: Three-year cohort study using VA and CC administrative data from the VA's Corporate Data Warehouse (October 1, 2016-September 30, 2019). We obtained Medicare data to capture readmissions that were paid by Medicare. We used the Centers for Medicare and Medicaid Services (CMS) methods to identify unplanned, 30-day, all-cause readmissions. A secondary outcome, TKA-related readmissions, identified readmissions resulting from complications of the index surgery. We ran mixed-effects logistic regression models to compare the risk-adjusted odds of all-cause and TKA-related readmissions between TKAs performed in VA versus CC, adjusting for patients' sociodemographic and clinical characteristics. PRINCIPAL FINDINGS: Nationally, the odds of experiencing an all-cause or TKA-related readmission were significantly lower for TKAs performed in VA versus CC (eg, the odds of experiencing an all-cause readmission in VA were 35% of those in CC. At the facility level, most VA facilities performed similarly to their corresponding CC providers, although there were 3 VA facilities that performed worse than their corresponding CC providers. CONCLUSIONS: Given VA's history in providing high-quality surgical care to Veterans, it is important to closely monitor and track whether the shift to CC for surgical care will impact quality in both settings over time.

Center differences in diabetes treatment outcomes among children with type 1 diabetes: A nationwide study of 3866 Danish children.

OBJECTIVE: Mean differences in HbA1c across centers are well established, but less well understood. The aim was to assess whether differences in patient case-mix can explain the variation in mean HbA1c between pediatric diabetes centers in Denmark. The association between HbA1c , frequency of blood glucose monitoring (BGM), treatment modality, and center visits was investigated. RESEARCH DESIGN AND METHODS: This longitudinal nationwide study included 3866 Danish children with type 1 diabetes from 2013 to 2017 (n = 12,708 child-year observations) from 16 different pediatric diabetes centers. Mean HbA1c , proportion of children reaching HbA1c treatment target (HbA1c  ≤ 58 mmol/mol [7.5%]) were compared across centers using linear regression models. This was done with and without adjustment for socioeconomic characteristics (patient case-mix). RESULTS: The mean difference in HbA1c during follow-up was 11.6 mmol/mol (95% CI 7.9, 15.3) (1.1% [95% CI 0.7, 1.4]) when comparing the centers with the lowest versus highest mean HbA1c . The difference was attenuated and remained significant after adjustment for the patient case-mix (difference: 10.5 mmol/mol [95% CI 6.8, 14.2] (1.0% [95% CI 0.6, 1.3])). Overall, 6.8% of the differences in mean HbA1c across centers were explained by differences in the patient case-mix. Across centers, more frequent BGM was associated with lower HbA1c . The proportion of insulin pump users and number of visits was not associated with HbA1c . CONCLUSION: In a setting of universal health care, large differences in HbA1c across centers were found, and could not be explained by patient background, number of visits or use of technology. Only BGM was associated with center HbA1c .