Investigating early readmission as an indicator for quality of care studies

Readmission to a hospital shortly following a previous discharge may be viewed as an adverse outcome of care. Consequently, early readmission represents a potentially useful indicator for monitoring quality. While a number of recent research studies have focused on this issue, several important questions concerning appropriate use of early readmission as a quality of care indicator remain to be addressed. In this article, using data on all discharges for 1 year from 18 hospitals, several of these questions are investigated. Specifically, whether the significant predictors of readmission risk are different for different types of cases (defined using DRGs), whether case severity is an important predictor of readmission risk, whether readmission risks differ systematically with hospital size and other characteristics, whether readmission risk is a function of patients' lengths-of-stay, and whether readmission risk is influenced by whether or not patients are discharged home or into organized care environments are explored. For this study, the focus is on patients who experienced unplanned readmissions to acute care hospitals within 31 days of a prior discharge. The Patient Management Category classification system and ICD-9-CM diagnosis and procedure codes are used to identify, and then exclude from consideration, those readmissions that occurred as part of an appropriately planned sequence of care. In each of 22 sets of related DRGs, analysis of unplanned readmissions indicates that severity/complexity is an important risk factor for early readmission and that clinical and other risk factors differ for different DRG groups. Thus, in future studies of early readmissions, researchers will need to control for both the type (e.g., DRG) and severity/complexity of individual cases. In examining relationships between early readmission and hospital characteristics, no consistent patterns suggestive of quality of care problems were detected.     

Tooth retention as an indicator of quality dental care: development of a risk adjustment model

BACKGROUND: Retaining teeth improves oral health and quality of life. Thus, receipt of a root canal (vs. a tooth extraction) is a useful indicator of the quality of dental care. However, use of this quality measure without adjusting for the severity of oral disease could lead to spurious conclusions. OBJECTIVES: This paper describes the development of a dental severity adjustment methodology. RESEARCH DESIGN: Retrospective study. SUBJECTS: 54,423 users of Department of Veterans Affairs (VA) dental care who had either root canal therapy or a tooth extraction at a VA facility in Fiscal year 1998. MEASURES: International Classification of Disease Clinical Modification codes for dental diagnoses and comorbid medical conditions. We modeled the effects of dental disease severity in logistic regression models of the probability of receiving a root canal, using both conceptual and Modified Delphi-Panel derived models, adjusting for age, and medical comorbidities. RESULTS: Conceptual and Modified Delphi models performed similarly. The dental disease severity adjustments increased the fit in models of the probability of receiving a root canal (C-statistic = 0.822 for the conceptual model and 0.804 for the Modified Delphi Panel model) compared with the model including comorbid medical conditions alone (C-statistic = 0.561). CONCLUSIONS: Risk adjustment for dental disease severity improves the fit of models of the probability of receiving a root canal. Studies of the quality of dental care should consider employing risk-adjusted models.     

Overall self-rated health: a new quality indicator for primary care

RATIONALE, AIMS AND OBJECTIVES: Patient 'empowerment' gives patients choices about their own care and about the outcomes they would most prefer. Many patients can be presumed to regard overall self-rated health as an important outcome. Therefore, overall self-rated health can be considered a relevant and important outcome measure for a patient-centred medical clinic. The purpose of this study was to use this new outcome measure as a dependent variable and to test the hypothesis that patients who are confident about their ability to manage their health will have better health, in comparison to more dependent patients. METHODS: We conducted a randomized cross-sectional postal survey of 500 veteran patients from the Panhandle of Texas and the surrounding areas; and 302 participated in the study. Multiple logistic regression analysis was used to test the hypothesis that health confidence is positively related to self-rated health, controlling for obesity, cigarette smoking and participation in recreational activities. RESULTS: Veterans who strongly disagreed with the statement that they usually could overcome illnesses on their own were less likely to report good, very good or excellent self-rated health (adjusted odds ratio=0.25). CONCLUSIONS: Overall self-rated health as measured by a single question proved to be significantly related to behavioural risk factors in this sample of primary care patients, attesting to its validity as an outcome indicator. Furthermore, health confidence was associated with better health. Most primary providers believe that they can, through good communication and providing self-care tools, increase healthy behaviours in their patients. If we are indeed able to increase health confidence in our patients, this study would suggest that self-rated health would improve.     

Analysis of biparietal diameter as an accurate indicator of gestational age

To date, there have been 25 studies attempting to correlate biparietal diameter and gestational age; of these, 17 meet specific criteria and thus are included in this evaluation. Although all studies have shown an increase in biparietal diameter with advancing gestational age, between 17 wk and term there is a discrepancy of approximately 3 wk. In this evaluation the charts are compared and the variations analyzed. An ideal table is constructed by combining the mean gestational age, calculated from a statistical analysis, and the variation at each millimeter point, determined by comparison of all the studies. It is hoped that this new 90% composite table, which consists of a range of gestational ages in weeks for each biparietal diameter, will not only provide more realistic indications of fetal age but also will serve as a reminder to sonographers, obstetricians, and patients of the relative accuracy and variations of biparietal diameter measurements.     

The impact of accurate patient assessment on quality of care

A nurse should be able to undertake and document a comprehensive, systematic and accurate nursing assessment of a patient. A review of the literature demonstrates a clear variation in the levels of assessment. This article examines the evolution of the nursing role and the implementation of assessment tools and looks at the potential for development within the profession.     

Patients' perceptions as an indicator of quality of care, in Greek patients with inflammatory bowel disease

Aim and method:  The chronic nature of inflammatory bowel disease (IBD) and its frequent relapses result to a considerable utilization of healthcare resources. Current approaches for the assessment of quality of care are based on the perception of the healthcare provider, which may be different from that of the healthcare user. The purpose of this study was to assess IBD patients' satisfaction, as an indicator of healthcare quality, with the use of a validated instrument (QUOTE-IBD). Ninety-five patients with IBD completed the GR-QUOTE-IBD questionnaire, for the assessment of patient's perception, regarding the quality of the perceived care.
Results:  According to this evaluation suboptimal care was observed in the dimensions of accommodation, accessibility and information (mean values: 8.92, 8.94 and 8.95, respectively). In the subgroup analysis significant differences were observed in relation to patient's age groups and educational level. Differences were also noted in relation to the disease duration (longer and shorter than 5 years).
Conclusions:  The assessment of the quality of health care, based on patients' perception, revealed quality problems in the dimensions of accommodation, accessibility and information. According to subgroup analysis, disease type, educational status, age and disease duration play an important role in the formation of patients' expectations from the healthcare system.     

Nosocomial infection rates as an indicator of quality

An interest in using nosocomial infection rates as an outcome measure to reflect quality of care in hospitals prompted us to consider factors in addition to quality that influence these rates. Approximately one third of nosocomial infections are potentially preventable, and changes in this "preventable" stratum of infections should reflect variations in quality. However, it will be necessary to identify those potentially preventable infections by calculating rates which are adjusted for intrinsic patient risk. Five other factors necessary for nosocomial infection rates to be a valid and reliable indicator of quality include identification of critical indicators (e.g., types of infection) and sampling schemes that most accurately reflect variations in quality; adoption of standardized, objective definitions of site-specific nosocomial infections; adoption of universal denominators across institutions; development of a monitoring system to assess compliance with surveillance and reporting procedures; and the adoption of more standardized training for infection control practitioners.     

伤口造口专科护理敏感质量指标体系的构建

目的 构建本土化、科学可靠的伤口造口专科护理敏感质量指标体系,为护理质量评价提供标准化工具。方法 2021年6月—12月,以“结构-过程-结果”质量评价模型为理论依据,基于循证分析和半结构式访谈制订函询问卷,通过德尔菲法确立指标体系,采用层次分析法确定指标权重。结果 2轮函询问卷的有效回收率分别为94.1%、100%,专家权威系数分别为0.897、0.931,肯德尔和谐系数分别为0.110～0.156、0.162～0.196,最终形成了包含3项一级指标、8项二级指标和20项三级指标的伤口造口专科护理敏感质量指标体系。结论 该指标体系具有较强的科学性、可靠性和临床适用性,符合伤口造口专科临床实践与护理管理特点,可为客观评价伤口造口专科护理质量提供参考依据。     

Patient education as a quality indicator in critical care: ischemic heart disease--recognition and response

Medical critical care unit (MCCU) nurses at a VA medical center designed a quality assurance monitor for educating cardiac patients. Patients with a diagnosis of rule-out myocardial infarction are interviewed about their preadmission use of nitroglycerin and entry into emergency treatment facilities. The MCCU nurses teach a five-point "ischemic heart disease--recognition and response" lesson, and ascertain the patient's immediate level of understanding. If the patient returns to the MCCU at a later date, nurses record the appropriateness of his use of nitroglycerin and entry into emergency treatment facilities. Thus, both short- and long-term gains in patient knowledge are assessed. Solutions to problems encountered in the quality assurance monitor implementation process are discussed. Benefits of the project to patients, the nursing department, and other departments are identified. A sample monthly report and the monitor data collection tool illustrate the process. Future directions for patient education efforts in the MCCU are outlined.