Quality Indicators for Evaluating the Health Care of Patients with Rheumatoid Arthritis: a Korean Expert Consensus

BackgroundThere is increasing interest in the quality of health care and considerable efforts are being made to improve it. Rheumatoid arthritis (RA) is a disease that can result in favorable outcomes when appropriate diagnosis and treatment are provided. However, several studies have shown that RA is often managed inappropriately. Therefore, the Korean College of Rheumatology aimed to develop quality indicators (QIs) to evaluate and improve the health care of patients with RA.MethodsPreliminary QIs were derived based on the existing guidelines and QIs for RA. The final QIs were determined through two separate consensus meetings of experts. The consensus was achieved through a panel of experts who voted using the modified Delphi method.ResultsFourteen final QIs were selected among 70 preliminary QIs. These included early referral to and regular follow-up with a rheumatologist, radiographs of the hands and feet, early initiation and maintenance of disease-modifying anti-rheumatic drug (DMARD) therapy, periodic assessment of disease activity, screening for drug safety and comorbidities, including viral hepatitis and tuberculosis before biologic DMARD therapy, periodic laboratory testing, supplementation with folic acid, assessment of the risk for cervical spine instability before general anesthesia, patient education, and specialized nurse.ConclusionThese QIs can be used to assess and improve the quality of health care for patients with RA.     

Psychological and relational factors in ESRD hemodialysis treatment in an underserved community

ObjectiveThe researchers investigated the association of depression with treatment adherence, and examined the possible moderating roles of social support and of the physician-patient working alliance (PPWA) on treatment adherence, satisfaction with treatment, and quality of life.MethodsThe current study sampled ninety-five patients with End Stage Renal Disease who were receiving outpatient hemodialysis (HD) treatment.ResultsFindings indicated that higher levels of depression were significantly associated with lower ratings of adherence, quality of life, and social support. In contrast, higher levels of social support and of the PPWA were significantly associated with higher ratings of adherence, satisfaction with treatment, and quality of life. Analyses of moderation showed no effect for PPWA between depression and adherence, satisfaction, or quality of life; however, there was a significant moderation effect for social support.ConclusionThere are mild but significant associations between PPWA and social support. Positive associations between the PPWA and social support on adherence, satisfaction, and quality of life indicate that each one, PPWA and social support, plays its own role on patients’ experiences of and behavior in treatment. Affective social support significantly limits the negative influence of depression on adherence.Practice ImplicationsAssessment of depression and social support is essential in hemodialysis treatment.     

Measurement of Quality Improvement in Family Practice over Two-year Period Using Electronic Database Quality Indicators: Retrospective Cohort Study from Israel

Aim

To investigate the associations between family physicians’ characteristics and the change in quality of health care indicators (QI) over a two-year period.

Methods

The retrospective cohort study included 161 (60.5%) of 266 family physicians who worked for the Clalit health fund in Israel in the period from January 2003 until December 2005. Family physicians'' background characteristics included seniority, location of the clinic (urban or rural), workload, sex, managerial responsibilities, and board certification. The performance in 11 QIs, including indicators of diabetes follow-up (n = 4) and control (n = 2), hospitalization for chronic obstructive pulmonary disease and congestive heart failure (n = 2), and preventive medicine measures (influenza immunization for high risk patients and mammography) was evaluated at the end of 2003 and 2005.

Results

There was an improvement in all the QIs except mammography. The improvement was significant for 8/10 QIs, the greatest being in achieving low-density lipoprotein cholesterol (+18.2%) and HbA1c (+5.9%) targets in diabetic patients. Multivariate regression model showed that the most significant factor associated with better QIs in December 2003 was board certification, while 2 years later it was female sex and having a managerial position. Being a board-certified physician remained positively associated with high QIs for diabetes control.

Conclusion

There was an improvement in most QIs in the period of 2 years. Initially, board certification was significantly associated with high QIs, but clinic managers and female physicians showed the ability to improve their scores. Research should continue to find ways to make all physicians responsive to their QIs.The use of quality of health care indicators (QI) has become increasingly common since the 1990s. Several factors have led to an increased interest in this method of assessment. Evidence based medicine allowed the best methods of treatment to be evaluated (1), while at the same time it acknowledged the variance in patient care (2). Social changes gave patients the right to question their health status, the quality of care they receive, or the performance of health care providers (3). In addition, health care providers and governments wanted to evaluate the services they paid for and find ways of improving the quality of health care. This all incited health service providers throughout the world – such as National Health Services in the UK (4) and the Health Plan Employer Data Information Set (HEDIS) (5), to start measuring QIs.Clalit Health Services (CHS), the largest health fund in Israel, began to measure QIs in 2001. The aim was to allow managers, physicians, and clinics to compare their performance among themselves and with targets set by the health fund and then to work on improving areas where they performed poorly (6). In March 2004, the Health Ministry in Israel published the first report on a national health care improvement project, using QIs as its basis. The data were collected from all 4 health care providers in Israel, covering the population of the entire state. The results from 2001-2003 showed a clear improvement in all the QIs. In 2004, the trend continued to be positive, although the improvement in some of the indicators was slow (7). It has to be noted that in Israel, unlike the UK, there is no monetary incentive for physicians to improve their quality of health care scores.The aim of this study was to identify primary care physicians’ (PCP) characteristics associated with their QI scores over 2 years.     

Adherence of cell-free DNA noninvasive prenatal screens to ACMG recommendations

PurposeNoninvasive prenatal screening (NIPS) for fetal aneuploidy via cell-free DNA has been commercially available in the United States since 2011. In 2016, the American College of Medical Genetics and Genomics (ACMG) issued a position statement with specific recommendations for testing laboratories. We sought to evaluate adherence to these recommendations.MethodsWe focused on commercial laboratories performing NIPS testing in the United States as of 1 January 2018. Sample laboratory reports and other materials were scored for compliance with ACMG recommendations. Variables scored for common and sex chromosome aneuploidy detection included detection rate, specificity, positive and negative predictive value, and fetal fraction. Labs that performed analysis of copy-number variants and results for aneuploidies other than those commonly reported were identified. Available patient education materials were similarly evaluated.ResultsNine of 10 companies reported fetal fraction in their reports, and 8 of 10 did not offer screening for autosomal aneuploidies beyond trisomy 13, 18, and 21. There was inconsistency in the application and reporting of other measures recommended by ACMG.ConclusionsLaboratories varied in the degree to which they met ACMG position statement recommendations. No company adhered to all laboratory guidance.     

Feasibility and Reliability of Interactive Voice Response Assessment of HIV Medication Adherence: Research and Clinical Implications

Abstract

Background: There are well-documented negative consequences of nonadherence to HIV medications. Telephone-based interactive voice response (IVR) technologies may hold promise for assessing nonadherence in both research and clinical contexts; however, little psychometric research has been conducted on this topic.Objective: In the present pilot study, we test the feasibility and reliability of a simplified patient-initiated, daily IVR system with a convenience sample of HIV patients attending a university-affiliated infectious disease clinic.Methods: Participants were asked to call in to an IVR system to report adherence daily during 2 weeks of a larger prospective study. Response rates and patterns were analyzed for feasibility and compared to retrospective, self-report timeline follow-back (TLFB) adherence reporting.Results: The IVR protocol showed moderate feasibility, with participants reporting adherence behavior on 63.4% of days. However, agreement with TLFB data was low, particularly for days in which participants reported incomplete adherence.Conclusions: The IVR protocol tested in the current trial shows some promise. Completion rates were higher than in previous trials. Future research is needed to further enhance the feasibility of IVR for HIV medication adherence and to compare responses to more objective measures on HIV adherence.     

Common sense model of self-regulation for understanding adherence and quality of life in type 2 diabetes with structural equation modeling

ObjectivesThe objective of the present study was to test the Common Sense Model of self-regulation (CSM) for its relevance for improving adherence and quality of life in type 2 diabetes.MethodsA sample of 253 patients with type 2 diabetes was recruited. They completed questionnaires about their perceptions regarding diabetes, coping strategies, therapeutic adherence and quality of life. Their HbA1c levels were also collected. Structural equation modeling (SEM) was used to check the adequacy of our theoretical model (CSM) with the patient data.ResultsThe final model indicated that perceptions were directly and indirectly related to health outcomes through coping strategies and adequately matched the data (χ² / df = 561/ 220 = 2.55; RMSEA = 0.08; PCFI = 0.66; PGFI = 0.70). Moreover, the model appeared to be identical for both types of treatment (oral and injectable).ConclusionsIllness perceptions and coping strategies, or, more specifically, how patients accept disease and think they are able to manage it, significantly affect therapeutic adherence and quality of life in type 2 diabetes.Practice implicationsThese results pave the way for developing psychological treatments aimed at improving patient acceptance and internal resources (e.g. use of autobiographical memory, Acceptance and Commitment Therapy).     

Predictors of late virologic failure after initial successful suppression of HIV replication on efavirenz-based antiretroviral therapy

Background: Practical issues, including cost, hinder implementing virologic monitoring of patients on antiretroviral therapy (ART) in resource-limited settings. We evaluated factors that might guide monitoring frequency and efforts to prevent treatment failure after initial virologic suppression.

Methods: Participants were the 911 HIV-infected antiretroviral-naïve adults with CD4 count <300 cells/μL who started efavirenz-based ART in the international A5175/PEARLS trial and achieved HIV-1 RNA <1000 copies/mL at 24 weeks. Participant report of ART adherence was evaluated using a structured questionnaire in monthly interviews. Adherence and readily available clinical and laboratory measures were evaluated as predictors of late virologic failure (late VF: confirmed HIV-1 RNA ≥1000 copies/mL after 24 weeks).

Results: During median follow-up of 3.5 years, 82/911 participants (9%) experienced late VF. Of 516 participants reporting missed doses during the first 24 weeks of ART, 55 (11%) experienced late VF, compared with 27 (7%) of 395 participants reporting no missed doses (hazard ratio: 1.73; 95% CI: 1.08, 2.73). This difference persisted in multivariable analysis, in which lower pre-ART hemoglobin and absence of Grade ≥3 laboratory results prior to week 24 were also associated with higher risk of late VF.

Discussion: In this clinical trial, the late VF rate after successful suppression was very low. If achievable in routine clinical practice, virologic monitoring involving infrequent (e.g. annual) measurements might be considered; the implications of this for development of resistance need evaluating. Patients reporting missed doses early after ART initiation, despite achieving initial suppression, might require more frequent measurement and/or strategies for promoting adherence.     

Outcomes of the PIRASOA programme,an antimicrobial stewardship programme implemented in hospitals of the Public Health System of Andalusia,Spain: an ecologic study of time-trend analysis

ObjectivesInappropriate antimicrobial use favours the spread of resistance, and multidrug-resistant microorganisms (MDR) are currently of major concern. Antimicrobial stewardship programmes (ASPs) are essential for improving antibiotic use in hospitals. However, their impact on entire healthcare systems has not been thoroughly assessed. Our objective was to provide the results of an institutionally supported ASP involving 31 public hospitals in Andalusia, Spain.MethodsWe designed an ecologic time-series study from 1 January 2014 to 31 December 2017. Quarterly, data on indicators were collected prospectively, and feedback reports were provided. PIRASOA is an ongoing clinically based quality-improvement programme whose key intervention is the educational interview, regular peer-to-peer interventions between advisors and prescribers to reinforce the appropriate use of antibiotics. Seventy-two indicators were monitored to measure prescribing quality (inappropriate treatments), antimicrobial consumption (defined daily doses per 1000 occupied bed-days), incidence density of MDR per 1000 occupied bed-days and crude mortality rate associated with bloodstream infections. We used Joinpoint regression software to analyse the trends.ResultsThe quality of antimicrobial prescribing improved markedly, and the inappropriate treatment rate was significantly lower, with quarterly percentage change (QPC) = −3.0%, p < 0.001. Total antimicrobial consumption decreased (QPC = −0.9%, p < 0.001), specifically carbapenems, amoxicillin/clavulanic acid, quinolones and antifungal agents, whereas antipseudomonal cephalosporin use increased. While the incidence of MDR showed a sustained decreasing trend (QPC = −1.8%; p 0.002), the mortality of patients with bloodstream infections remained stable (QPC = −0.2%, p 0.605).ConclusionsTo date, the PIRASOA programme has succeeded in optimizing the use of antimicrobial agents and has had a positive ecologic result on bacterial resistance at level of an entire healthcare system.     

Quality indicators in Transfusion Medicine: the building blocks

Background Over the past two decades the quest for safe blood supply has led to tremendous growth in the content and scope of the science and practice of Transfusion Medicine (TM). The desire by the various stakeholders in the blood establishment for zero-risk blood transfusion has not only stretched the level of quality expected of the Transfusion Medicine Service to apical height, but has also resulted in the demand by these stakeholders for concrete proofs that expected degrees of quality have been met or preferably exceeded. Quality indicators (QIs) are a Quality Management System (QMS) tool that are instituted in an organization with intent on not just providing this much needed proof of the level of quality performance tenable in the organization, but they are also intent on utilizing the information gained to seek improving the quality of performance in the organization. In the last decade, huge efforts have been exerted by government and non-government hospital-based blood banks, national and international organizations to collate, select, establish and analyze quality QIs for several dimensions of healthcare quality. Notable contributions have been made by such eminent bodies as the Agency for Healthcare Research and Quality (AHRQ), the Organization for Economic Cooperation and Development (OECD) and the College of American Pathologists (CAP). Unfortunately these efforts have only sparsely addressed quality indicators for TM. A year ago, the International Society of Blood Transfusion (ISBT) instituted its Working Party on Quality Management (WPQM). Quality indicators for TM are of priority to the WPQM which presumably is intent on redressing this imbalance and providing robust and valid quality indicators to monitor quality performances in key processes and outcomes in TM practice, globally. Objective This paper therefore highlights some basic essentials for successful monitoring of quality of transfusion medicine service through appropriate selection and implementation of quality indicator projects. It is hoped the information shared through this medium might be of value to Transfusion Medicine practitioners as well as to the ISBT WPQM as they thinker with quality indicators for Transfusion Medicine. Material and Method Considerable review of published literature in the form of journal articles, books and online publications on quality management and quality indicators in Healthcare/Transfusion Medicine was performed with the view to extract essentials elements that could be considered building blocks for the selection, implementation, analysis and utilization of quality indicators in Transfusion Medicine. Result Elements deemed as essential building blocks that were appraised included, but were not limited to: understanding Transfusion Medicine terrain; concept of quality and quality indicators selection criteria; choice of improvement model, data analysis and manner of communication of findings as well as the role of effective education and leadership. Conclusion Quality indicators are indispensible tools which various stakeholders in the Blood Transfusion establishment now demand to adjudge and improve on quality performance. Practitioners as well as policy makers in Transfusion Medicine need to ensure that the quality indicators they institute are appropriately selected and analyzed to be effective and efficient monitors of quality. Knowledge of basic building blocks discussed here is therefore a fundamental prerequisite.     

The effects of self-management education tailored to health literacy on medication adherence and blood pressure control among elderly people with primary hypertension: A randomized controlled trial

ObjectiveTo evaluate the effects of self-management education tailored to health literacy on medication adherence and blood pressure control.MethodThis randomized controlled trial was conducted in 2018 with 118 elderly people with uncontrolled primary hypertension and inadequate health literacy. Self-management education was developed on the basis of the health literacy index. Medication adherence and blood pressure were assessed using 8-items Morisky Medication Adherence Scale and a mercury sphygmomanometer, respectively.ResultsAt baseline, there were no significant between-group differences regarding participants’ demographic characteristics, medical history, and medication adherence. After the intervention, between-group comparisons adjusted for pretest scores showed a significant reduction in the mean score of systolic and diastolic blood pressure and increase adherence to medication due to intervention (P < 0.05). However, the proportions of controlled systolic and diastolic blood pressure were not statistically significant different between-group (P > 0.05).ConclusionSelf-management education tailored to health literacy significantly promotes medication adherence but has no significant effects on control of blood pressure.Practice implicationTo promote adherence to antihypertensive medications, tailored patient education to Health literacy is recommended. Limited pieces of evidence are available on the effectiveness of health literacy index-based interventions, so further studies are required.     

Development of quality indicators to evaluate the monitoring of SLE patients in routine clinical practice

The assessment of systemic lupus erythematosus (SLE) patients in routine clinical practice is mainly based on the experience of the treating physician. This carries the risk of unwanted variability. Variability may have an impact on the quality of care offered to SLE patients, thereby affecting outcomes. Recommendations represent systematically developed statements to help practitioners in reducing variability. However, major difficulties arise in the application of recommendations into clinical practice. In this respect, the use of quality indicators may raise the awareness among rheumatologists regarding potential deficiencies in services and improve the quality of health care. The aim of this study was to develop a set of quality indicators (QI) for SLE by translating into QIs the recently developed EULAR Recommendations for monitoring SLE patients in routine clinical practice and observational studies. Eleven QIs have been developed referring to the use of validated activity and damage indices in routine clinical practice, general evaluation of drug toxicity, evaluation of comorbidities, eye evaluation, laboratory assessment, evaluation of the presence of chronic viral infections, documentation of vaccination and of antibody testing at baseline. A disease specific set of quality assessment tools should help physicians deliver high quality of care across populations. Routine updates will be needed.     

A review of randomized controlled trials of medical record powered clinical decision support system to improve quality of diabetes care

BackgroundA gap between current diabetes care practice and recommended diabetes care standards has consistently been reported in the literature. Many IT-based interventions have been developed to improve adherence to the quality of care standards for chronic illness like diabetes.ObjectiveThe widespread implementation of electronic medical/health records has catalyzed clinical decision support systems (CDSS) which may improve the quality of diabetes care. Therefore, the objective of the review is to evaluate the effectiveness of CDSS in improving quality of type II diabetes care. Moreover, the review aims to highlight the key indicators of quality improvement to assist policy makers in development of future diabetes care policies through the integration of information technology and system.Selection of studySetting inclusion criteria, a systematic literature search was conducted using Medline, Web of Science and Science Direct. Critical Appraisal Skills Programme (CASP) tools were used to evaluate the quality of studies. Eight randomized controlled trials (RCTs) were selected for the review. In the selected studies, seventeen clinical markers of diabetes care were discussed. Three quality of care indicators were given more importance in monitoring the progress of diabetes care, which is consistent with National Institute for Health and Care Excellence (NICE) guidelines. The presence of these indicators in the studies helped to determine which studies were selected for review. Clinical- and process-related improvements are compared between intervention group using CDSS and control group with usual care. Glycated hemoglobin (HbA1c), low density lipid cholesterol (LDL-C) and blood pressure (BP) were the quality of care indicators studied at the levels of process of care and clinical outcome.FindingsThe review has found both inconsistent and variable results for quality of diabetes care measures. A significant improvement has been found in the process of care for all three measures of quality of diabetes care. However, weak to modest positive results are observed for the clinical measures of the diabetes care indicators. In addition to this, technology adoption of CDSS is found to be consistently low.ConclusionThe review suggests the need to conduct further empirical research using the critical diabetes care indicators (HbA1c, LDL-C and BP) to ascertain if CDSS improves the quality of diabetes care. Research designs should be improved, especially with regard to baseline characteristics, sample size and study period. With respect to implementation of CDSS, rather than a sudden change of clinical work practice, there should instead be an incremental, gradual adoption of technology that minimizes the disruption in clinical workflow.     

Quality of life of adult individuals with intestinal stomas in Uganda: a cross sectional study

IntroductionIntestinal stomas remain important life-saving surgical options in a wide range of gastrointestinal pathologies globally. Living with a stoma has potential to impair the patient''s quality of life, often with associated negative psychological effects.ObjectiveTo evaluate the quality of life among intestinal stoma patients under Mulago National Referral Hospital (MNRH), with emphasis on psychological effects and effects on family-social interactions.MethodologyA cross-sectional study carried out at surgical outpatient clinics of MNRH between January and June 2018. Data was collected using Stoma-QOL questionnaire, PHQ-9 and GAD-7 from 51 participants who had lived with intestinal stomas for at least a month.ResultsOf the 51 participants, male: female ratio was 4:1 and aged 18–84 years (mean age 44.04+18.47 years). 76.5% had colostomy; 23.5% had ileostomy. Majority (88.2%) had temporary stomas. The overall mean Stoma-QOL score was 55.12+ 17.04. Only about a quarter (24%) of participants had Stoma-QOL scores >70 (best). Most patients exhibited negative psychological effects (anxiety-100%, concerns about changed body image - 96.1% and depression - 88.4%).ConclusionMost participants had low levels of stoma-related quality of life, suffered negative psychological effects and exhibited limited social interactions. This calls for efforts to support Stoma patients adapt beter life.     

Clinical progression and predictors of death in patients with severe fever with thrombocytopenia syndrome in China

BackgroundSevere fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease of which the clinical progression and factors related to death are still unclear.ObjectiveTo identify the clinical progression of SFTS and explore predictors of fatal outcome throughout the disease progress.Study designA prospective study was performed in a general hospital located in Xinyang city during 2011–2013. Confirmed SFTS patients were recruited and laboratory parameters that were commonly evaluated in clinical practice were collected. The clinical progression was determined based on analysis of dynamic profiles and Friedman's test. At each clinical stage, the laboratory features that could be used to predict fatal outcome of SFTS patients were identified by stepwise discriminant analysis.ResultsTotally 257 survivors and 54 deceased SFTS patients were recruited and the data of 11 clinical and laboratory parameters along their entire disease course were consecutively collected. Three clinical stages (day 1–5 post onset, day 6–11 post onset and day 12 to hospital discharge) were determined based on distinct clinical parameters evaluations. Multivariate discriminant analysis at each clinical stage disclosed the indicators of the fatal outcome as decreased platelet counts at early stage, older age and increased AST level at middle stage, and decreased lymphocyte percentage and increased LDH level at late stage.ConclusionsThe significant indicators at three clinical stages could be used to assist identifying the patients with high risk of death. This knowledge might help to perform supportive treatment and avoid fatality.     

Culture media for clinical bacteriology in low- and middle-income countries: challenges,best practices for preparation and recommendations for improved access

BackgroundCulture media are fundamental in clinical microbiology. In laboratories in low- and middle-income countries (LMICs), they are mostly prepared in-house, which is challenging.ObjectivesThis narrative review describes challenges related to culture media in LMICs, compiles best practices for in-house media preparation, gives recommendations to improve access to quality-assured culture media products in LMICs and formulates outstanding questions for further research.SourcesScientific literature was searched using PubMed and predefined MeSH terms. In addition, grey literature was screened, including manufacturer's websites and manuals as well as microbiology textbooks.ContentBacteriology laboratories in LMICs often face challenges at multiple levels: lack of clean water and uninterrupted power supply, high environmental temperatures and humidity, dust, inexperienced and poorly trained staff, and a variable supply of consumables (often of poor quality). To deal with this at a base level, one should be very careful in selecting culture media. It is recommended to look for products supported by the national reference laboratory that are being distributed by an in-country supplier. Correct storage is key, as is appropriate preparation and waste management. Centralized media acquisition has been advocated for LMICs, a role that can be taken up by the national reference laboratories, next to guidance and support of the local laboratories. In addition, there is an important role in tropicalization and customization of culture media formulations for private in vitro diagnostic manufacturers, who are often still unfamiliar with the LMIC market and the plethora of bacteriology products.ImplicationThe present narrative review will assist clinical microbiology laboratories in LMICs to establish best practices for handling culture media by defining quality, regulatory and research paths.     

Effects of the ISO 15189 accreditation on Nagoya University Hospital

The Department of Clinical Laboratory, Nagoya University Hospital acquired ISO 15189 accreditation in November, 2009. The operation of our Quality Management System (QMS) was first surveyed in October, 2010. In this paper, we reported the activity for the preparation and operation of our QMS and the effects of ISO 15189 accreditation. We investigated the changes in the number and content on nonconformities, incident reports and complaints before and after accreditation as indicators to evaluate the effect of ISO 15189 accreditation. Post accreditation, the number of nonconformities and incident reports decreased, seeming to show an improvement of quality of the laboratory activity; however, the number of complaints increased. We identified the increase of complaints at the phlebotomy station. There had been some problems with blood sampling in the past, but it seemed that staff had a high level of concern regarding these problems at the phlebotomy station and took appropriate measures to resolve the complaints. We confirmed that the ISO 15189 accreditation was instrumental in the improvements of the safety and efficiency on laboratory works. However there was a problem that increase of overtime works to operate the QMS. We deal with development of a laboratory management system using IT recourses to solve the problem.