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Mortality, readmission and length of stay have different relationships using hospital-level versus patient-level data: an example of the ecological fallacy affecting hospital performance indicators

Quality and Safety in Health Care Journal -

Background

Ecological fallacy refers to an erroneous inference about individuals on the basis of findings for the group to which those individuals belong. Suppose analysis of a large database shows that hospitals with a high proportion of long length of stay (LOS) patients also have higher than average in-hospital mortality. This may prompt efforts to reduce mortality among patients with long LOS. But patients with long LOS may not be the ones at higher risk of death. It may be that hospitals with higher mortality (regardless of LOS) also have more long LOS patients—either because of quality problems on both counts or because of unaccounted differences in case mix. To provide more insight how the ecological fallacy influences the evaluation of hospital performance indicators, we assessed whether hospital-level associations between in-hospital mortality, readmission and long LOS reflect patient-level associations.

Methods

Patient admissions from the Dutch National Medical Registration (2007–2012) for specific diseases (stroke, colorectal carcinoma, heart failure, acute myocardial infarction and hip/knee replacements in patients with osteoarthritis) were analysed, as well as all admissions. Logistic regression analysis was used to assess patient-level associations. Pearson correlation coefficients were used to quantify hospital-level associations.

Results

Overall, we observed 2.2% in-hospital mortality, 8.1% readmissions and a mean LOS of 5.9 days among 8 478 884 admissions in 95 hospitals. Of the 10 disease-specific associations tested, 2 were reversed at hospital-level, 3 were consistent and 5 were only significant at either hospital-level or patient-level. A reversed association was found for stroke: patients with long LOS had 58% lower in-hospital mortality (OR 0.42 (95% CI 0.40 to 0.44)), whereas the hospital-level association was reversed (r=0.30, p<0.01). Similar negative patient-level associations were found for each hospital, but LOS varied across hospitals, thereby resulting in a positive hospital-level association. A similar effect was found for long LOS and readmission in patients with heart failure.

Conclusions

Hospital-level associations did not reflect the same patient-level associations in 7 of 10 associations, and were even reversed in 2 associations. Ecological fallacy thus potentially influences interpretation of hospital performance when patient-level associations are not taken into account.

Simplifying care: when is the treatment burden too much for patients living in poverty?

Quality and Safety in Health Care Journal -

It is usually a grand affair when ‘Ms Noelle’ makes it to clinic. The 52-year-old mother with a history of hepatitis C cirrhosis, hypertension, uterine fibroids and migraines has been in our care for over a year. Even so, each visit still brings a new crisis. Today, we found out that Ms Noelle, the caretaker of a daughter with bipolar disorder and nine grandchildren, had just been evicted from her home. She had been without any income for months, and her applications for temporary cash assistance and disability were denied. Ms Noelle maintained a remarkable ability to keep her family protected and fed despite all this, but we have watched as she became the ultimate victim: she struggled to remember her medications, their doses and indications, and her cirrhosis was frequently on the verge of decompensation during appointments she was barely able to keep. She was overwhelmed by even...

Dynamics of dignity and safety: a discussion

Quality and Safety in Health Care Journal -

Introduction

‘Do no harm’ is an enduring principle of medicine, yet people continue to be harmed in the process of being ‘cared for’. Before the 1990s, there was very little understanding that poor quality might be inherent in the structures and processes of the healthcare system.1 Now, as a result of considerable research investment, a great deal is known about, for example, hospital-acquired infection, surgical error, medication error, and the systems and processes that predispose practitioners towards error. Nevertheless, what it means to ‘care’ and how this might carry threats to safety has recently been exemplified by events at Mid Staffordshire NHS Foundation Trust in the UK. Here, there were consistently higher than average mortality rates and poor standards of care in which patients’ most basic needs were routinely overlooked; personal hygiene, nutrition and hydration were not maintained, and patients were treated without compassion or respect for...

Implementation of diagnostic pauses in the ambulatory setting

Quality and Safety in Health Care Journal -

Background

Diagnostic errors result in preventable morbidity and mortality. The outpatient setting may be at increased risk, where time constraints, the indolent nature of outpatient complaints and single decision-maker practice models predominate.

Methods

We developed a self-administered diagnostic pause to address diagnostic error. Clinicians (physicians and nurse practitioners) in an academic primary care setting received the tool if they were seeing urgent care patients who had previously been seen in the past two weeks in urgent care. We used pre–post-intervention surveys, focus groups and chart audits 6 months after the urgent care visit to assess the impact of the intervention on participant perceptions and actions.

Results

We piloted diagnostic pauses in two phases (3 months and 6 months, respectively); 9 physicians participated in the first phase, and 16 physicians and 2 nurse practitioners in the second phase. Subjects received 135 alerts for diagnostic pauses and responded to 82 (61% response). Thirteen per cent of alerts resulted in clinicians reporting new actions as a result of the diagnostic pauses. Thirteen per cent of cases at a 6-month chart audit resulted in diagnostic discrepancies, defined as differences in diagnosis from the initial working diagnosis. Focus groups reported that the diagnostic pauses were brief and fairly well integrated into the overall workflow for evaluation but would have benefited as a real-time application for patients at higher risk for diagnostic error.

Conclusion

This pilot represents the first known examination of diagnostic pauses in the outpatient setting, and this work potentially paves the way for more broad-based systems and/or electronic interventions to address diagnostic error.

2017 Thank you to our frequent reviewers

Quality and Safety in Health Care Journal -

We would like to extend our gratitude to all of our reviewers for making it possible for BMJ Quality and Safety to publish the highest quality content by providing their rigorous clinical, scientific, or methodological expertise. Their efforts to respect requested deadlines and take the time to provide detailed reviews have also enabled us to achieve excellent turnaround times and offer an excellent service to our authors. Below is a list of all reviewers who have reviewed more than 3 manuscripts for the Journal in 2017. We are grateful to all of our reviewers, and a full list of all of those who have reviewed at least one manuscript for BMJ Quality & Safety can be found online at http://qualitysafety.bmj.com/thank-you-to-our-reviewers/

Aylin, Paul

Bahl, Vinita

Bottle, Alex

Burke, Robert

Card, Alan

Dainty, Katie

Dhaliwal, Gurpreet

Jeffs, Lianne

Jheeta, Seetal

Lisby, Marianne

Lyndon, Audrey

Mackintosh, Nicola

O’Hara, Jane

Ramsay, Angus

...

Low-value care: an intractable global problem with no quick fix

Quality and Safety in Health Care Journal -

Low-value care, or patient care that provides no net benefit in specific clinical scenarios, remains one of the most pressing problems in healthcare across the world—namely because it raises costs, causes iatrogenic patient harm, and often interferes with the delivery of high-value care. Many have argued that above all else the primary cause of low-value care lies in an unchecked fee-for-service payment system, which creates a pervasive culture that rewards providers for delivering more care, not necessarily the right care. Results reported by McAlister et al in this issue of BMJ Quality & Safety seem to up-end this belief.1 In their analysis of 3.4 million beneficiaries in the globally-budgeted health system of Alberta, Canada, they found that low-value care commonly occurred—at a rate of approximately 5% of beneficiaries seeking care, and as high as 30% among those aged >75 years. Notably, these rates are comparable to rates in America’s largely...

Advancing the science of patient decision aids through reporting guidelines

Quality and Safety in Health Care Journal -

Patient decision aids (PDAs) are tools designed to help people make deliberative choices about their healthcare options using the best available evidence. They provide balanced information about treatment choices and help patients construct, clarify and communicate what is important to them in making healthcare choices. PDAs can prepare patients to make informed, values-based decisions with their healthcare providers.1–3 The evidence base on PDAs has grown rapidly over the past two decades. The most recent update to the Cochrane systematic review of PDAs included 105 randomised controlled trials published through April 2015.2 This number excludes trials comparing complex to simpler PDAs and other evaluations of PDAs using non-randomised designs. People who use decision aids improve their knowledge of the options, report feeling clearer and better informed about the options, have more accurate expectations about benefits and harms of options, and participate more in...

Frequency of low-value care in Alberta, Canada: a retrospective cohort study

Quality and Safety in Health Care Journal -

Objective

To determine how frequently 10 low-value services highlighted by Choosing Wisely are done and what factors influence their provision.

Methods

This is a retrospective cohort study using routinely collected health data from five linked data sets from 2012 to 2015 in the Canadian province of Alberta to determine the frequency with which 10 low-value services were provided.

Results

Between 2012 and 2015, 162 143 people (4% of all 3 814 536 adult Albertans and 5% of the 3 423 135 who saw a physician at least once in that time frame) received at least one of the 10 low-value services, including 29.8% of Albertans older than 75 years (57 811 of 194 068). The proportion of adults receiving low-value services ranged from carotid artery imaging in 0.1% of asymptomatic adults without cerebrovascular disease, to prostate-specific antigen (PSA) testing in 55.5% of men 75 years or older without a history of prostate cancer. Although age, Charlson scores and frequency of primary care visits were associated with low-value service provision, the directions of the association differed across services; however, higher socioeconomic status, increased frequency of specialist contact and higher ratio of specialists to primary care physicians in the patient’s region were associated with an increased risk of receiving all of the low-value services we examined. The low-value services which resulted in the greatest costs to the healthcare system were cervical cancer screening in women older than 65 without history of cervical dysplasia or genital cancer, PSA testing in men older than 75 without history of prostate cancer and preoperative stress testing/cardiac imaging before non-cardiac surgery.

Conclusions

Even within a universal coverage healthcare system, the proportion of patients receiving low-value services varied widely (from <0.1% to 56%). Increased use was associated with higher socioeconomic status, increased frequency of specialist contact and higher ratio of specialists to primary care physicians.

Increasing the use of patient decision aids in orthopaedic care: results of a quality improvement project

Quality and Safety in Health Care Journal -

Objective

To integrate patient decision aid (DA) delivery to promote shared decision-making and provide more patient-centred care within an orthopaedic surgery department for treatment of hip and knee osteoarthritis, lumbar herniated disc and lumbar spinal stenosis.

Methods

Different strategies were used across three distinct phases to promote DA delivery. First, we used a quality improvement bonus to generate awareness and interest in the DAs among specialists. Second, we adapted the electronic referral management system to enable DA orders at referral to a specialist. Third, we engaged clinic staff and specialists to design workflows that promoted DA delivery. We tracked the number of patients who received a DA, who ordered the DA, and collected usage data from a subset of patients. Our target was to reach 60% of patients with DAs.

Results

In phase 1, 28% (43/155) of spine patients and 37% (114/308) of hip/knee patients received a DA. In phase 2, 54% (64/118) of spine referrals and 58% (189/324) of hip/knee referrals included a request to send a patient a DA. In phase 3, 56% (90/162) of spine patients and 69% (213/307) of hip/knee patients received a DA, significantly more than in phase 1 (P<0.0001). In phase 3, both more DAs were ordered by clinic staff compared with specialists (56% phase 3 vs 34% phase 1, P<0.001) and sent before the visit (74% phase 3 vs 17% phase 1, P<0.001). Patients were more likely to report reviewing the DA when delivered before the visit (63% before vs 50% after, P=0.005).

Conclusion

DA implementation into clinic workflow is possible and facilitated by engagement of the entire care team and the support of health information technology.

Precommitting to choose wisely about low-value services: a stepped wedge cluster randomised trial

Quality and Safety in Health Care Journal -

Background

Little is known about how to discourage clinicians from ordering low-value services. Our objective was to test whether clinicians committing their future selves (ie, precommitting) to follow Choosing Wisely recommendations with decision supports could decrease potentially low-value orders.

Methods

We conducted a 12-month stepped wedge cluster randomised trial among 45 primary care physicians and advanced practice providers in six adult primary care clinics of a US community group practice.Clinicians were invited to precommit to Choosing Wisely recommendations against imaging for uncomplicated low back pain, imaging for uncomplicated headaches and unnecessary antibiotics for acute sinusitis. Clinicians who precommitted received 1–6 months of point-of-care precommitment reminders as well as patient education handouts and weekly emails with resources to support communication about low-value services.The primary outcome was the difference between control and intervention period percentages of visits with potentially low-value orders. Secondary outcomes were differences between control and intervention period percentages of visits with possible alternate orders, and differences between control and 3-month postintervention follow-up period percentages of visits with potentially low-value orders.

Results

The intervention was not associated with a change in the percentage of visits with potentially low-value orders overall, for headaches or for acute sinusitis, but was associated with a 1.7% overall increase in alternate orders (p=0.01). For low back pain, the intervention was associated with a 1.2% decrease in the percentage of visits with potentially low-value orders (p=0.001) and a 1.9% increase in the percentage of visits with alternate orders (p=0.007). No changes were sustained in follow-up.

Conclusion

Clinician precommitment to follow Choosing Wisely recommendations was associated with a small, unsustained decrease in potentially low-value orders for only one of three targeted conditions and may have increased alternate orders.

Trial registration number

NCT02247050; Pre-results.

Development of the Huddle Observation Tool for structured case management discussions to improve situation awareness on inpatient clinical wards

Quality and Safety in Health Care Journal -

Background

‘Situation Awareness For Everyone’ (SAFE) was a 3-year project which aimed to improve situation awareness in clinical teams in order to detect potential deterioration and other potential risks to children on hospital wards. The key intervention was the ‘huddle’, a structured case management discussion which is central to facilitating situation awareness. This study aimed to develop an observational assessment tool to assess the team processes occurring during huddles, including the effectiveness of the huddle.

Methods

A cross-sectional observational design was used to psychometrically develop the ‘Huddle Observation Tool’ (HOT) over three phases using standardised psychometric methodology. Huddles were observed across four NHS paediatric wards participating in SAFE by five researchers; two wards within specialist children hospitals and two within district general hospitals, with location, number of beds and length of stay considered to make the sample as heterogeneous as possible. Inter-rater reliability was calculated using the weighted kappa and intraclass correlation coefficient.

Results

Inter-rater reliability was acceptable for the collaborative culture (weighted kappa=0.32, 95% CI 0.17 to 0.42), environment items (weighted kappa=0.78, 95% CI 0.52 to 1) and total score (intraclass correlation coefficient=0.87, 95% CI 0.68 to 0.95). It was lower for the structure and risk management items, suggesting that these were more variable in how observers rated them. However, agreement on the global score for huddles was acceptable.

Conclusion

We developed an observational assessment tool to assess the team processes occurring during huddles, including the effectiveness of the huddle. Future research should examine whether observational evaluations of huddles are associated with other indicators of safety on clinical wards (eg, safety climate and incidents of patient harm), and whether scores on the HOT are associated with improved situation awareness and reductions in deterioration and adverse events in clinical settings, such as inpatient wards.

Does early return to theatre add value to rates of revision at 3 years in assessing surgeon performance for elective hip and knee arthroplasty? National observational study

Quality and Safety in Health Care Journal -

Background

Joint replacement revision is the most widely used long-term outcome measure in elective hip and knee surgery. Return to theatre (RTT) has been proposed as an additional outcome measure, but how it compares with revision in its statistical performance is unknown.

Methods

National hospital administrative data for England were used to compare RTT at 90 days (RTT90) with revision rates within 3 years by surgeon. Standard power calculations were run for different scenarios. Funnel plots were used to count the number of surgeons with unusually high or low rates.

Results

From 2006 to 2011, there were 297 650 hip replacements (HRs) among 2952 surgeons and 341 226 knee replacements (KRs) among 2343 surgeons. RTT90 rates were 2.1% for HR and 1.5% for KR; 3-year revision rates were 2.1% for HR and 2.2% for KR. Statistical power to detect surgeons with poor performance on either metric was particularly low for surgeons performing 50 cases per year for the 5 years. The correlation between the risk-adjusted surgeon-level rates for the two outcomes was +0.51 for HR and +0.20 for KR, both p<0.001. There was little agreement between the measures regarding which surgeons had significantly high or low rates.

Conclusion

RTT90 appears to provide useful and complementary information on surgeon performance and should be considered alongside revision rates, but low case loads considerably reduce the power to detect unusual performance on either metric.

Standards for UNiversal reporting of patient Decision Aid Evaluation studies: the development of SUNDAE Checklist

Quality and Safety in Health Care Journal -

Background

Patient decision aids (PDAs) are evidence-based tools designed to help patients make specific and deliberated choices among healthcare options. The International Patient Decision Aid Standards (IPDAS) Collaboration review papers and Cochrane systematic review of PDAs have found significant gaps in the reporting of evaluations of PDAs, including poor or limited reporting of PDA content, development methods and delivery. This study sought to develop and reach consensus on reporting guidelines to improve the quality of publications evaluating PDAs.

Methods

An international workgroup, consisting of members from IPDAS Collaboration, followed established methods to develop reporting guidelines for PDA evaluation studies. This paper describes the results from three completed phases: (1) planning, (2) drafting and (3) consensus, which included a modified, two-stage, online international Delphi process. The work was conducted over 2 years with bimonthly conference calls and three in-person meetings. The workgroup used input from these phases to produce a final set of recommended items in the form of a checklist.

Results

The SUNDAE Checklist (Standards for UNiversal reporting of patient Decision Aid Evaluations) includes 26 items recommended for studies reporting evaluations of PDAs. In the two-stage Delphi process, 117/143 (82%) experts from 14 countries completed round 1 and 96/117 (82%) completed round 2. Respondents reached a high level of consensus on the importance of the items and indicated strong willingness to use the items when reporting PDA studies.

Conclusion

The SUNDAE Checklist will help ensure that reports of PDA evaluation studies are understandable, transparent and of high quality. A separate Explanation and Elaboration publication provides additional details to support use of the checklist.

Explanation and elaboration of the Standards for UNiversal reporting of patient Decision Aid Evaluations (SUNDAE) guidelines: examples of reporting SUNDAE items from patient decision aid evaluation literature

Quality and Safety in Health Care Journal -

This Explanation and Elaboration (E&E) article expands on the 26 items in the Standards for UNiversal reporting of Decision Aid Evaluations guidelines. The E&E provides a rationale for each item and includes examples for how each item has been reported in published papers evaluating patient decision aids. The E&E focuses on items key to reporting studies evaluating patient decision aids and is intended to be illustrative rather than restrictive. Authors and reviewers may wish to use the E&E broadly to inform structuring of patient decision aid evaluation reports, or use it as a reference to obtain details about how to report individual checklist items.

Quality measurement for Clostridium difficile infection: turning lemons into lemonade

Quality and Safety in Health Care Journal -

W Edwards Deming is famously quoted as having said, "If you can’t measure it, you can’t manage it". In truth, Deming’s full quotation reads, "It is wrong to suppose that if you can’t measure it, you can’t manage it—a costly myth".1 2 In our journey to improve our hospital’s rates of Clostridium difficile, we learned first-hand the truth of Deming’s full statement—that in fact, even without the ability to measure perfectly, imperfect measures can still help us improve quality.

US hospitals are currently required to report hospital-acquired C. difficile rates as a condition of participation in several Centers for Medicare and Medicaid Services (CMS) pay-for-performance programmes. CMS is seeking to shed light on this type of preventable patient harm and raising the stakes by putting financial penalties and a hospital’s public reputation at risk. However, there is a vigorous debate in the medical community over the...

Medline Remedy Essentials No-Rinse Cleansing Foam: Avoid Using - Multistate Outbreak of Burkholderia Cepacia Complex

FDA MedWatch -

CDC reports that there are 10 confirmed cases of infection caused by bacteria within the Burkholderia cepacia complex, also commonly called B. cepacia, in three states: California (2), Pennsylvania (7), and New Jersey (1). These patients were already hospitalized for acute conditions and acquired the infections while hospitalized. The infections have been linked to the Medline product, Remedy Essentials No-Rinse Cleansing Foam.

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