Comparison of clinical and administrative data sources for hospital coronary artery bypass graft surgery report cards.
(1/20)
BACKGROUND: Regardless of statistical methodology, public performance report cards must use the highest-quality validated data, preferably from a prospectively maintained clinical database. Using logistic regression and hierarchical models, we compared hospital cardiac surgery profiling results based on clinical data with those derived from contemporaneous administrative data. METHODS AND RESULTS: Fiscal year 2003 isolated coronary artery bypass grafting surgery results based on an audited and validated Massachusetts clinical registry were compared with those derived from a contemporaneous state administrative database, the latter using the inclusion/exclusion criteria and risk model of the Agency for Healthcare Research and Quality. There was a 27.4% disparity in isolated coronary artery bypass grafting surgery volume (4440 clinical, 5657 administrative), a 0.83% difference in observed in-hospital mortality (2.05% versus 2.88%), corresponding differences in risk-adjusted mortality calculated by various statistical methodologies, and 1 hospital classified as an outlier only with the administrative data-based approach. The discrepancies in volumes and risk-adjusted mortality were most notable for higher-volume programs that presumably perform a higher proportion of combined procedures that were misclassified as isolated coronary artery bypass grafting surgery in the administrative cohort. Subsequent analyses of a patient cohort common to both databases revealed the smoothing effect of hierarchical models, a 9% relative difference in mortality (2.21% versus 2.03%) resulting from nonstandardized mortality end points, and 1 hospital classified as an outlier using logistic regression but not using hierarchical regression. CONCLUSIONS: Cardiac surgery report cards using administrative data are problematic compared with those derived from audited and validated clinical data, primarily because of case misclassification and nonstandardized end points. (+info)
Bridging the gap between evidence and practice in venous thromboembolism prophylaxis: the quality improvement process.
(2/20)
Venous thromboembolism (VTE) is considered to be the most common preventable cause of hospital-related death. Hospitalized patients undergoing major Surgery and hospitalized patients with acute medical illness have an increased risk of VTE. Although there is overwhelming evidence for the need and efficacy of VTE prophylaxis in patients at risk, only about a third of those who are at risk of VTE receive appropriate prophylaxis. To address the shortfall in VTE prophylaxis, the US Joint Commission and the National Quality Forum (NQF) endorse standardized VTE prophylaxis practices, and are identifying and testing measures to monitor these standards. Hospitals in the USA accredited by Centers for Medicare and Medicaid Services to receive medicare patients will need VTE prophylaxis programs in place to conform to these national consensus standards. This review aims to give background information on initiatives to improve the prevention of VTE and to identify key features of a successful quality improvement strategy for prevention of VTE in the hospital. A literature review shows that the key features of effective quality improvement strategies includes an active strategy, a multifaceted approach, and a continuous iterative process of audit and feedback. Risk assessment models may be helpful for deciding which patients should receive prophylaxis and for matching VTE risk with the appropriate intensity of prophylaxis. This approach should assist in implementing the NQF/Joint Commission-endorsed standards, as well as increase the use of appropriate VTE prophylaxis. (+info)
The impact of a citywide audit with educational intervention on the care of patients with epilepsy.
(3/20)
The care of patients with epilepsy historically has been well documented to be poor. Previous attempts to improve care through education have been unsuccessful. The New GP Contract in the UK introduced epilepsy as a core quality indicator from April 2004. This prospective audit assesses the impact of an audit with educational intervention on the process of care of patients with epilepsy. The case notes of 610 patients, of all ages, with epilepsy on treatment, in 13 general practices serving Chester and surrounding area were reviewed before and 2 years after an intervention, comprising (a) the provision of a comprehensive template, (b) individualised categorisation for each patient and (c) an educational session led by a Neurologist. The overall review rate increased in the first year from 41 to 49% (p<0.0001) and by 2 years to 63% (p<0.0001). Documented remission rate increased from 29 to 43% (p<0.0001). Admissions to accident and emergency fell significantly (p=0.0026). There was no fall in the non-compliance rate. Forty five percent of patients with documented poor control were not under shared care. Issues highlighted in the audit generated 77 referrals. There were clear health gains in 62 (13%) individuals from referrals and practice interventions related to the audit. This original audit identified significant improvements in review rate, documented remission rate and beneficial outcomes in individual patients. The changes were attributable to both the educational intervention and the coincidental acceptance of the New GP Contract. Remaining problems include lack of shared care for patients with active epilepsy. (+info)
Use of a registry-generated audit, feedback, and patient reminder intervention in an internal medicine resident clinic--a randomized trial.
(4/20)
BACKGROUND: Disease registries, audit and feedback, and clinical reminders have been reported to improve care processes. OBJECTIVE: To assess the effects of a registry-generated audit, feedback, and patient reminder intervention on diabetes care. DESIGN: Randomized controlled trial conducted in a resident continuity clinic during the 2003-2004 academic year. PARTICIPANTS: Seventy-eight categorical Internal Medicine residents caring for 483 diabetic patients participated. Residents randomized to the intervention (n = 39) received instruction on diabetes registry use; quarterly performance audit, feedback, and written reports identifying patients needing care; and had letters sent quarterly to patients needing hemoglobin A1c or cholesterol testing. Residents randomized to the control group (n = 39) received usual clinic education. MEASUREMENTS: Hemoglobin A1c and lipid monitoring, and the achievement of intermediate clinical outcomes (hemoglobin A1c <7.0%, LDL cholesterol <100 mg/dL, and blood pressure <130/85 mmHg) were assessed. RESULTS: Patients cared for by residents in the intervention group had higher adherence to guideline recommendations for hemoglobin A1c testing (61.5% vs 48.1%, p = .01) and LDL testing (75.8% vs 64.1%, p = .02). Intermediate clinical outcomes were not different between groups. CONCLUSIONS: Use of a registry-generated audit, feedback, and patient reminder intervention in a resident continuity clinic modestly improved diabetes care processes, but did not influence intermediate clinical outcomes. (+info)
Quantifying data quality for clinical trials using electronic data capture.
(5/20)
Will the NHHRC recommendations drive quality performance?
(6/20)
General practice is the heart of the Australian health care system, addressing the health needs of people, in their communities and in diverse locations and contexts across Australia. With over 100 million items of service claimed by general practitioners each year, even small but incremental improvements in quality have the potential to translate into population level gains in the outcomes and safety of general practice care. In recent years, Australian general practice has undertaken significant work in quality improvement, with practice accreditation to The Royal Australian College of General Practitioners standards and the Australian Primary Care Collaboratives Program being examples. Will the recommendations of the National Health and Hospitals Reform Commission (NHRC) enhance this work? (+info)
Improving GP diabetes management - A PDSA audit cycle in Western Australia.
(7/20)
BACKGROUND: Tight glucose, blood pressure and lipid control in patients with diabetes can reduce morbidity and mortality from macro- and micro-vascular complications. However, treatment targets are not being met in a large proportion of patients. Clinical audit involves cycles of evaluation of current activity against standards. It allows problems to be identified and action to be taken to address them. METHODS: Annual retrospective audits over 3 years of random samples of up to 20 patient medical records from 13 general practitioners in the midwest region of Western Australia (n=807). Statistical tests compared the second and third audits with the first in regard to completeness of screening, health indicators, and the proportion of patients within The Royal Australian College of General Practitioners and Diabetes Australia guidelines targets. RESULTS: While there was a significant improvement in lipid monitoring over the study period (p<0.001), monitoring of HbA1c and blood pressure (BP) remained unchanged. Between the first and third audits, a reduction in mean HbA1c (p<0.001), mean total cholesterol (p=0.017), mean LDL cholesterol (p=0.014) and mean systolic BP (p=0.002) was seen. There was an improvement in the proportion of patients achieving cholesterol goals (measured by LDL and reaching a target of HbA1c <7%) between the first and third audits; however the proportion with BP within target declined. In the third audit, 11% of patients on diet alone, 36% on an oral hypoglycaemic agent, 90% on three oral hypoglycaemic agents and 84% of those on insulin were outside the target HbA1c. In the same audit, of those outside target BP, 53% were on no treatment and 65% were only on one type of medication. Eighty-seven percent of patients outside target cholesterol levels had not been prescribed a statin. DISCUSSION: Many of the audited GPs in our study undertreated BP, HbA1c and cholesterol. Improvement in some areas was seen over the study period, which may have been due to the quality assurance activities undertaken. These results reveal a therapeutic opportunity for reducing cardiovascular events in patients with diabetes. More aggressive management of BP and lipids by GPs may see rewards in terms of reducing cardiovascular events in patients with diabetes. (+info)
The Stroke Practice Improvement Network: a quasiexperimental trial of a multifaceted intervention to improve quality.
(8/20)