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Hopes, Worries for US Health Care in Wake of COVID-19: A Q&A With Donald M. Berwick, MD, MPP

Institute for Healthcare Improvement -

To mark the 25th anniversary of the American Journal of Managed Care, each issue in 2020 will include an interview with a healthcare thought leader. For the June issue, AJMC turned to Donald M. Berwick, MD, MPP, president emeritus and senior fellow at the Institute for Healthcare Improvement and former administrator of CMS.

Weekend effect: complex metric for a complex pathway

Quality and Safety in Health Care Journal -

‘Time is tissue’ has become a mantra in emergency care: delays in treatment limit the opportunity to minimise damage caused by trauma and ischaemia, particularly for conditions like acute stroke or myocardial infarction where drugs and techniques can restore blood flow. The therapeutic time window may have widened for some forms of acute ischaemic stroke,1 2 but that does not mean that time is no longer critical. For ST-segment elevation myocardial infarction (STEMI), survival rates are higher if balloon angioplasty is performed earlier than 90 min from hospital presentation.3 4 Efforts to improve patient outcomes further by reducing time to treatment have taken a ‘whole pathway’ approach, from initial symptoms in the community to definitive intervention in the hospital. These have included raising public awareness,5 evaluating different routes of urgent referral to hospital6 and investigating the timing of...

Approach to making the availability heuristic less available

Quality and Safety in Health Care Journal -

Introduction

Errors in judgement are often traceable to pitfalls of human reasoning. One pitfall is the availability heuristic, defined as a tendency to judge the likelihood of a condition by the ease at which examples spring to mind. This intuition is often a great approximation but can be sometimes mistaken because of fallible memories. People, for example, may mistakenly believe drowning causes fewer deaths than fires in the USA (actual deaths in 2017: drowning=3709 vs fires=2812)1 because they cannot easily recall many news stories about drowning. Calm water is boring to imagine whereas bright flames are dramatic images vividly recalled and frequently popularised. In turn, people can underestimate the risks lurking in lakes or rivers and neglect basic safety strategies. This may be an example where the availability heuristic could cause a fatal mistake.

Diagnostic errors can also stem from the availability heuristic and contribute to serious...

Improving cardiac surgical quality: lessons from the Japanese experience

Quality and Safety in Health Care Journal -

In this issue of BMJ Quality & Safety, Yamamoto and colleagues1 describe an innovative national quality improvement intervention to identify and remediate low-performing Japanese cardiac surgery programmes. This is the most recent of numerous quality initiatives by Japanese cardiothoracic surgical leaders,2–11 and they deserve recognition for their ambitious and ongoing efforts. In 2000, emulating the Society of Thoracic Surgeons Database,12 they developed the Japan Cardiovascular Surgery Database (JCVSD), the foundation for all their subsequent quality activities. Because their board certification requires JCVSD participation,4 this assures that every board-certified cardiac surgeon, and presumably every CT programme, has access to rigorous, nationally benchmarked results. With their newest quality programme, these results are used to target low-performing centres. What can we learn from their experience, and...

What are we doing when we double check?

Quality and Safety in Health Care Journal -

Double checking is often considered a useful strategy to detect and prevent medication errors, especially before the administration of high-risk drugs.1 2 From a safety research perspective, the effectiveness of double checking in preventing medication errors is limited by several factors,3 4 even if they are conducted independently5: a double check represents a barrier designed to catch errors before they reach the patient. If it is carried out by two people (compared with a technology-based check, like barcode scanning), the detection rate is limited because both people may be affected by the same disturbances in the environment, for example, noise, confusing drug labels or cognitive biases in information processing (eg, confirmation bias6 7). Double checks also may become a mindless routine over time,3 7 meaning that the checking persons rely on...

The relationship between off-hours admissions for primary percutaneous coronary intervention, door-to-balloon time and mortality for patients with ST-elevation myocardial infarction in England: a registry-based prospective national cohort study

Quality and Safety in Health Care Journal -

Background

The degree to which elevated mortality associated with weekend or night-time hospital admissions reflects poorer quality of care (‘off-hours effect’) is a contentious issue. We examined if off-hours admissions for primary percutaneous coronary intervention (PPCI) were associated with higher adjusted mortality and estimated the extent to which potential differences in door-to-balloon (DTB) times—a key indicator of care quality for ST elevation myocardial infarction (STEMI) patients—could explain this association.

Methods

Nationwide registry-based prospective observational study using Myocardial Ischemia National Audit Project data in England. We examined how off-hours admissions and DTB times were associated with our primary outcome measure, 30-day mortality, using hierarchical logistic regression models that adjusted for STEMI patient risk factors. In-hospital mortality was assessed as a secondary outcome.

Results

From 76 648 records of patients undergoing PPCI between January 2007 and December 2012, we included 42 677 admissions in our analysis. Fifty-six per cent of admissions for PPCI occurred during off-hours. PPCI admissions during off-hours were associated with a higher likelihood of adjusted 30-day mortality (OR 1.13; 95% CI 1.01 to 1.25). The median DTB time was longer for off-hours admissions (45 min; IQR 30–68) than regular hours (38 min; IQR 27–58; p<0.001). After adjusting for DTB time, the difference in adjusted 30-day mortality between regular and off-hours admissions for PPCI was attenuated and no longer statistically significant (OR 1.08; CI 0.97 to 1.20).

Conclusion

Higher adjusted mortality associated with off-hours admissions for PPCI could be partly explained by differences in DTB times. Further investigations to understand the off-hours effect should focus on conditions likely to be sensitive to the rapid availability of services, where timeliness of care is a significant determinant of outcomes.

'Immunising physicians against availability bias in diagnostic reasoning: a randomised controlled experiment

Quality and Safety in Health Care Journal -

Background

Diagnostic errors have often been attributed to biases in physicians’ reasoning. Interventions to ‘immunise’ physicians against bias have focused on improving reasoning processes and have largely failed.

Objective

To investigate the effect of increasing physicians’ relevant knowledge on their susceptibility to availability bias.

Design, settings and participants

Three-phase multicentre randomised experiment with second-year internal medicine residents from eight teaching hospitals in Brazil.

Interventions

Immunisation: Physicians diagnosed one of two sets of vignettes (either diseases associated with chronic diarrhoea or with jaundice) and compared/contrasted alternative diagnoses with feedback. Biasing phase (1 week later): Physicians were biased towards either inflammatory bowel disease or viral hepatitis. Diagnostic performance test: All physicians diagnosed three vignettes resembling inflammatory bowel disease, three resembling hepatitis (however, all with different diagnoses). Physicians who increased their knowledge of either chronic diarrhoea or jaundice 1 week earlier were expected to resist the bias attempt.

Main outcome measurements

Diagnostic accuracy, measured by test score (range 0–1), computed for subjected-to-bias and not-subjected-to-bias vignettes diagnosed by immunised and not-immunised physicians.

Results

Ninety-one residents participated in the experiment. Diagnostic accuracy differed on subjected-to-bias vignettes, with immunised physicians performing better than non-immunised physicians (0.40 vs 0.24; difference in accuracy 0.16 (95% CI 0.05 to 0.27); p=0.004), but not on not-subjected-to-bias vignettes (0.36 vs 0.41; difference –0.05 (95% CI –0.17 to 0.08); p=0.45). Bias only hampered non-immunised physicians, who performed worse on subjected-to-bias than not-subjected-to-bias vignettes (difference –0.17 (95% CI –0.28 to –0.05); p=0.005); immunised physicians’ accuracy did not differ (p=0.56).

Conclusions

An intervention directed at increasing knowledge of clinical findings that discriminate between similar-looking diseases decreased physicians’ susceptibility to availability bias, reducing diagnostic errors, in a simulated setting. Future research needs to examine the degree to which the intervention benefits other disease clusters and performance in clinical practice.

Trial registration number

68745917.1.1001.0068.

Quality improvement in cardiovascular surgery: results of a surgical quality improvement programme using a nationwide clinical database and database-driven site visits in Japan

Quality and Safety in Health Care Journal -

Background

In 2015, an academic-led surgical quality improvement (QI) programme was initiated in Japan to use database information entered from 2013 to 2014 to identify institutions needing improvement, to which cardiovascular surgery experts were sent for site visits. Here, posthoc analyses were used to estimate the effectiveness of the QI programme in reducing surgical mortality (30-day and in-hospital mortality).

Methods

Patients were selected from the Japan Cardiovascular Surgery Database, which includes almost all cardiovascular surgeries in Japan, if they underwent isolated coronary artery bypass graft (CABG), valve or thoracic aortic surgery from 2013 to 2016. Difference-in-difference methods based on a generalised estimating equation logistic regression model were used for pre-post comparison after adjustment for patient-level expected surgical mortality.

Results

In total, 238 778 patients (10 172 deaths) from 590 hospitals, including 3556 patients seen at 10 hospitals with site visits, were included from January 2013 to December 2016. Preprogramme, the crude surgical mortality for site visit and non-site visit institutions was 9.0% and 2.7%, respectively, for CABG surgery, 10.7% and 4.0%, respectively, for valve surgery and 20.7% and 7.5%, respectively, for aortic surgery. Postprogramme, moderate improvement was observed at site visit hospitals (3.6%, 9.6% and 18.8%, respectively). A difference-in-difference estimator showed significant improvement in CABG (0.29 (95% CI 0.15 to 0.54), p<0.001) and valve surgery (0.74 (0.55 to 1.00); p=0.047). Improvement was observed within 1 year for CABG surgery but was delayed for valve and aortic surgery. During the programme, institutions did not refrain from surgery.

Conclusions

Combining traditional site visits with modern database methodologies effectively improved surgical mortality in Japan. These universal methods could be applied via a similar approach to contribute to achieving QI in surgery for many other procedures worldwide.

Impact of structured interdisciplinary bedside rounding on patient outcomes at a large academic health centre

Quality and Safety in Health Care Journal -

Background

Effective communication between healthcare providers and patients and their family members is an integral part of daily care and discharge planning for hospitalised patients. Several studies suggest that team-based care is associated with improved length of stay (LOS), but the data on readmissions are conflicting. Our study evaluated the impact of structured interdisciplinary bedside rounding (SIBR) on outcomes related to readmissions and LOS.

Methods

The SIBR team consisted of a physician and/or advanced practice provider, bedside nurse, pharmacist, social worker and bridge nurse navigator. Outcomes were compared in patients admitted to a hospital medicine unit using SIBR (n=1451) and a similar control unit (n=770) during the period of October 2016 to September 2017. Multivariable negative binomial regression analysis was used to compare LOS and logistic regression analysis was used to calculate 30-day and 7-day readmission in patients admitted to SIBR and control units, adjusting for covariates.

Results

Patients admitted to SIBR and control units were generally similar (p≥0.05) with respect to demographic and clinical characteristics. Unadjusted readmission rates in SIBR patients were lower than in control patients at both 30 days (16.6% vs 20.3%, p=0.03) and 7 days (6.3% vs 9.0%, p=0.02) after discharge, while LOS was similar. After adjusting for covariates, SIBR was not significantly related to the odds of 30-day readmission (OR 0.81, p=0.07) but was lower for 7-day readmission (OR 0.70, p=0.03); LOS was similar in both groups (p=0.58).

Conclusion

SIBR did not reduce LOS and 30-day readmissions but had a significant impact on 7-day readmissions.

On selecting quality indicators: preferences of patients with breast and colon cancers regarding hospital quality indicators

Quality and Safety in Health Care Journal -

Background

There is an increasing number of quality indicators being reported publicly with aim to improve the transparency on hospital care quality. However, they are little used by patients. Knowledge on patients’ preferences regarding quality may help to optimise the information presented to them.

Objective

To measure the preferences of patients with breast and colon cancers regarding publicly reported quality indicators of Dutch hospital care.

Methods

From the existing set of clinical quality indicators, participants of patient group discussions first assessed an indicator’s suitability as choice information and then identified the most relevant ones. We used the final selection as attributes in two discrete choice experiments (DCEs). Questionnaires included choice vignettes as well as a direct ranking exercise, and were distributed among patient communities. Data were analysed using mixed logit models.

Results

Based on the patient group discussions, 6 of 52 indicators (breast cancer) and 5 of 21 indicators (colon cancer) were selected as attributes. The questionnaire was completed by 84 (breast cancer) and 145 respondents (colon cancer). In the patient group discussions and in the DCEs, respondents valued outcome indicators as most important: those reflecting tumour residual (breast cancer) and failure to rescue (colon cancer). Probability analyses revealed a larger range in percentage change of choice probabilities for breast cancer (10.9%–69.9%) relative to colon cancer (7.9%–20.9%). Subgroup analyses showed few differences in preferences across ages and educational levels. DCE findings partly matched with those of direct ranking.

Conclusion

Study findings show that patients focused on a subset of indicators when making their choice of hospital and that they valued outcome indicators the most. In addition, patients with breast cancer were more responsive to quality information than patients with colon cancer.

Novel quality improvement method to reduce cost while improving the quality of patient care: retrospective observational study

Quality and Safety in Health Care Journal -

Background

Healthcare cost management strategies are limited in number and resource intensive. Budget constraints in the National Health Service Scotland (NHS Scotland) apply pressure on regional health boards to improve efficiency while preserving quality.

Methods

We developed a technical method to assist health systems to reduce operating costs, called continuous value management (CVM). Derived from lean accounting and employing quality improvement (QI) methods, the approach allows for management to reduce or repurpose resources to improve efficiency. The primary outcome measure was the cost per patient admitted to the ward in British pounds (£).

Interventions

The first step of CVM is developing a standard care model. Teams then track system performance weekly using a tool called the ‘box score’, and improve performance using QI methods with results displayed on a visual management board. A 29-bed inpatient respiratory ward in a mid-sized hospital in NHS Scotland pilot tested the method.

Results

We included 5806 patients between October 2016 and May 2018. During the 18-month pilot, the ward realised a 21.8% reduction in cost per patient admitted to the ward (from an initial average level of £807.70 to £631.50 as a new average applying Shewhart control chart rules, p<0.0001), and agency nursing spend decreased by 30.8%. The ward realised a 28.9% increase in the number of patients admitted to the ward per week. Other quality measures (eg, staff satisfaction) were sustained or improved.

Conclusion

CVM methods reduced the cost of care while improving quality. Most of the reduction came by way of reduced bank nursing spend. Work is under way to further test CVM and understand leadership behaviours supporting scale-up.

Effectiveness of double checking to reduce medication administration errors: a systematic review

Quality and Safety in Health Care Journal -

Background

Double checking medication administration in hospitals is often standard practice, particularly for high-risk drugs, yet its effectiveness in reducing medication administration errors (MAEs) and improving patient outcomes remains unclear. We conducted a systematic review of studies evaluating evidence of the effectiveness of double checking to reduce MAEs.

Methods

Five databases (PubMed, Embase, CINAHL, Ovid@Journals, OpenGrey) were searched for studies evaluating the use and effectiveness of double checking on reducing medication administration errors in a hospital setting. Included studies were required to report any of three outcome measures: an effect estimate such as a risk ratio or risk difference representing the association between double checking and MAEs, or between double checking and patient harm; or a rate representing adherence to the hospital’s double checking policy.

Results

Thirteen studies were identified, including 10 studies using an observational study design, two randomised controlled trials and one randomised trial in a simulated setting. Studies included both paediatric and adult inpatient populations and varied considerably in quality. Among three good quality studies, only one showed a significant association between double checking and a reduction in MAEs, another showed no association, and the third study reported only adherence rates. No studies investigated changes in medication-related harm associated with double checking. Reported double checking adherence rates ranged from 52% to 97% of administrations. Only three studies reported if and how independent and primed double checking were differentiated.

Conclusion

There is insufficient evidence that double versus single checking of medication administration is associated with lower rates of MAEs or reduced harm. Most comparative studies fail to define or investigate the level of adherence to independent double checking, further limiting conclusions regarding effectiveness in error prevention. Higher-quality studies are needed to determine if, and in what context (eg, drug type, setting), double checking produces sufficient benefits in patient safety to warrant the considerable resources required.

CRD42018103436.

Accuracy of quality measurement for the Hospital Acquired Conditions Reduction Program

Quality and Safety in Health Care Journal -

To the Editor

The Centres for Medicare and Medicaid Services (CMS) announced the Hospital Acquired Conditions Reduction Program (HACRP) in 2013, which penalises the 25% of hospitals in USA with the highest rates of hospital-acquired conditions (HACs). CMS uses two domains to measure the incidence of conditions for this programme—the Agency for Healthcare Research and Quality’s Patient Safety Indicators (PSI-90) (Domain 1) and the National Healthcare Safety Network (NHSN) hospital-associated infection measures (Domain 2). Domain 2 constitutes 85% of the total score used to levy financial penalties against hospitals. The PSI-90 composite is derived from Medicare claims; the NHSN measures are derived from an electronic registry managed by the Centres for Disease Control and Prevention. While many agree that reducing harm from hospitalisations is an important national priority, there are concerns that the PSI-90 composite is not valid,1 2 the NHSN measures may undercount...

Quality & safety in the literature: July 2020

Quality and Safety in Health Care Journal -

Healthcare quality and safety span multiple topics across the spectrum of academic and clinical disciplines. Keeping abreast of the rapidly growing body of work can be challenging. In this series, we provide succinct summaries of selected relevant studies published in the last several months. Some articles will focus on a particular theme, while others will highlight unique publications from high-impact medical journals.

Key points

  • In a randomised clinical trial, use of 16 symptom-specific cognitive aids significantly reduced omitted critical management steps for surgical teams in simulation scenarios involving deteriorating postoperative patients. JAMA Surgery. 27 November 2019.

  • Retrospective analysis of electronic health records, combined with institutional telecommunication logs, showed incoming telephone call interruptions for paediatric intensive care unit nurses were significantly and temporally associated with medication administration errors. Errors also varied by shift, nurse experience in the unit, nurse-to-patient ratio and level of patient...

  • GSK Consumer Healthcare Issues Voluntary Nationwide Recall of Children's Robitussin® Honey Cough and Chest Congestion DM and Children's Dimetapp® Cold and Cough Due to Dosing Cups Missing Some Graduation Markings

    FDA MedWatch -

    GSK Consumer Healthcare is voluntarily recalling to the retail level two lots (listed below) of Children’s Robitussin® Honey Cough and Chest Congestion DM and one lot of Children’s Dimetapp® Cold and Cough, due to the inclusion of incorrect dosing cups.

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