Improving quality through cost recovery in Niger.

To assess the impact of an intervention consisting of a computer-assisted clinical decision support system and performance-based incentives, aiming at improving quality of antenatal and childbirth care. Intervention study in rural primary healthcare (PHC) facilities in Burkina Faso, Ghana and Tanzania. In each country, six intervention and six non-intervention PHC facilities, located in one intervention and one non-intervention rural districts, were selected. Quality was assessed in each facility by health facility surveys, direct observation of antenatal and childbirth care, exit interviews, and reviews of patient records and maternal and child health registers. Findings of pre- and post-intervention and of intervention and non-intervention health facility quality assessments were analysed and assessed for significant (P < 0.05) quality of care differences. Post-intervention quality scores do not show a clear difference to pre-intervention scores and scores at non-intervention facilities. Only a few variables had a statistically significant better post-intervention quality score and when this is the case this is mostly observed in only one study-arm, being pre-/post-intervention or intervention/non-intervention. Post-intervention care shows similar deficiencies in quality of antenatal and childbirth care and in detection, prevention, and management of obstetric complications as at baseline and non-intervention study facilities. Our intervention study did not show a significant improvement in quality of care during the study period. However, the use of new technology seems acceptable and feasible in rural PHC facilities in resource-constrained settings, creating the opportunity to use this technology to improve quality of care.

The authors sought to update and expand the evidence on the quality of health care and disparities in care among Medicaid beneficiaries with schizophrenia. Adult beneficiaries of New York State Medicaid with schizophrenia receiving care during 2016-2019 were identified. Composite quality scores were derived from item response theory models by using evidence-based indicators of the quality of mental and general medical health care. Risk-adjusted racial-ethnic differences in quality were estimated and summarized as percentiles relative to White beneficiaries' mean quality scores. The study included 71,013 beneficiaries; 42.8% were Black, 22.9% Latinx, 27.4% White, and 6.9% other race-ethnicity. Overall, 68.8% had a mental health follow-up within 30 days of discharge, and 90.2% had no preventable hospitalizations for chronic obstructive pulmonary disease or asthma. Among beneficiaries receiving antipsychotic medications, medication adherence was adequate for 43.7%. Fourteen indicators for mental and general medical health care quality yielded three composites: two for mental health care (pharmacological and ambulatory) and one for acute mental and general medical health care. Mean quality of pharmacological mental health care for Black and Latinx beneficiaries was lower than for White beneficiaries (39th and 44th percentile, respectively). For Black beneficiaries, mean quality of ambulatory mental health care was also lower (46th percentile). In New York City, Black beneficiaries received lower-quality care in all domains. The only meaningful group difference in the quality of acute mental and general medical health care indicated higher-quality care for individuals with other race-ethnicity. Disparities in the quality of Medicaid-financed health care persist, particularly for Black beneficiaries. Regional differences merit further attention.

Significant percentage of health care services for rural Nigerians is being provided in rural health facilities by rurally based doctors, nurses, midwifes and other categories of health professionals. These services include general medical and obstetric care as well elective and urgent surgeries. As a result of these, there is likelihood of a decrease in the need for rural people to travel to major centres to seek health care service except for referral purposes. Medical education and health service management policy appear to support the location of tertiary and secondary health facilities in urban areas to the detriment of rural community health care. Hence there is an assumption, without much evidence, that the quality of care in rural hospitals' is lower than that provided in larger urban hospitals. Also there is dearth of literature on the aspects of heath care to be measured to indicate quality. This article reports an exploration of multiple perspectives on what constitutes quality of care in rural community medical practice. This is a multiple perspective analytical study. Data were obtained from a series of 134 individual patient cases involving internal medicine, obstetric and surgical procedures in small to large rural hospitals. Interviews were conducted with several participants in each case and these include doctors; nurses; midwives; patients; and family members of the patients. The interviews also explored the perspectives of individuals in each group on the broader question of what constitutes quality of care in a general sense. Their comments were subjected to qualitative analysis using SPSS software package. The different groups produced different views on what might determine the quality of health care in rural community hospitals. The health professionals tended to focus on technical aspects of care, although the doctors and nurses had some different emphases, while the patients and their families were more concerned with access, interpersonal communication, convenience and cost. These factors appeared to be consistent with previous literature from general healthcare settings. Some indicators were suggested for measuring the quality of rural health care. The contribution of this study to knowledge is in area of improvement of understanding of the differing views held by rural health professionals, patients and patients' families in thinking about the quality of care provided in rural community health facilities. Consideration of the quality of procedural rural medical care should include the needs and expectations of those living and working in a smaller, more familiar environment. This has implications for health planners, and suggests that there is a continuing need for rural health professionals to be trained to provide procedural medical services in rural hospitals, and for rural hospitals to be maintained at a standard necessary to support quality service provision.Keywords: Nigeria; quality of health care; experiences; perspectives; rural community Nigerian Medical Practitioner Vol. 50 (2) 2006: pp 48-53

Mental Health Care Reforms in Latin America: Child and Adolescent Mental Health Services in Mexico

Efforts to develop quantitative indicators of quality of care for family planning services, and to evaluate its role in contraceptive behavior, remain at an early stage. The present study, based upon an analysis of prospective data from a sample of 7,800 reproductive-aged rural Bangladeshi women, provides empirical evidence on the importance of quality of care for contraceptive practice. The results demonstrate that the perceptions of women regarding the quality of field-worker care were significantly related to the probability of subsequent adoption of a family planning method. Women who were not using a method and who scored high on an index of perceived quality of care were 27 percent more likely to adopt a method subsequently, compared with women with a low score. Effects were even more pronounced for contraceptive continuation; high quality of care was associated with a 72 percent greater likelihood of continued use of any method of contraception.

THE MODERN ACADEMIC QUALITY IMPROVEMENT movement began more than 40 years ago with a series of articles that highlighted substantial deficiencies in the way care was provided. In response, multiple efforts to improve quality were launched. Medical processes that affected patients’ health were identified. Methods of measuring how well the processes were performed in day-to-day practice were developed, and many suggestions were made regarding how the processes could be performed better and care improved. Everyone got into the act. The US government established organizations to review quality of care on an areawide or geographic basis. Hospital accreditation organizations changed their focus from improving the structure of facilities (eg, bricks and mortar, licensure) to what was done to patients, and eventually, to what happened to patients. Organizations were developed to accredit and examine quality of care in the outpatient arena. Hospitals developed quality assurance departments. Organizations such as the Institute for Healthcare Improvement blossomed into leaders in the field of quality improvement, helping institutions provide a better product. Businesses and corporations formed groups to focus the attention of the health care profession on producing a higher-quality product. More than 40 years later it is unclear what the quality movement has accomplished. Very little is known about how many dollars are invested to improve quality of care nationally or who makes that investment, and there is insufficient evidence about whether or how the quality of care has actually improved. However, what is known is that there is a long way to go. There is no yearly clinically detailed comprehensive report on the epidemiology of quality. Quality can be defined with more reliability and validity, but there is little information about which mechanisms for improving quality work better than others. More than a decade ago, as the quality improvement movement seemed to stall, many, including the Institute of Medicine, questioned whether the words or concept “quality of health care” had caught the attention of the US public and whether sufficient resources were being invested in the quality movement to actually improve care. As a result, there was a major effort to relabel and morph the quality improvement movement into the patient safety movement. The difference between quality and safety is not clear. If a surgeon removes the wrong limb, is that a quality problem or a safety problem? Are errors of commission (ie, placing a feeding tube in the lungs as opposed to the stomach) and errors of omission (ie, failing to give a surgical patient anticoagulation) problems of quality or safety? In any event, refocusing quality to safety seemed to have reenergized the quality improvement movement for a period. However, the change did not produce the sustained momentum desired by leaders. So the quality improvement movement began to change again. The focus shifted from improving the outcome of care (ie, health of patients) to establishing a business case for quality. The argument was that in most industries improving the quality of the product saved money (fewer recalls, better and less expensive products), so investing in quality of health care should also save money. Organizations and researchers trying to obtain grant funding were asked to demonstrate the business case for quality. Although there are some examples in the literature to support the concept that better quality of care is less expensive, few studies have produced information that could be generalized across time and institutional settings. Indeed, it is the rare article that actually includes measurement of cost or expenditures in a study that attempts to improve quality. Of course, many chief executive officers in organizations from insurance companies to nursing homes invest in and evaluate projects designed both to improve quality and reduce cost. However, the information derived from such activities is not generally in the public domain.

We adapted a rapid quality of care monitoring method to a fragile state with two aims: to assess the delivery of child health services in South Sudan at the time of independence and to strengthen local capacity to perform regular rapid health facility assessments. Using a two-stage lot quality assurance sampling (LQAS) design, we conducted a national cross-sectional survey among 156 randomly selected health facilities in 10 states. In each of these facilities, we obtained information on a range of access, input, process and performance indicators during structured interviews and observations. Quality of care was poor with all states failing to achieve the 80% target for 14 of 19 indicators. For example, only 12% of facilities were classified as acceptable for their adequate utilisation by the population for sick-child consultations, 16% for staffing, 3% for having infection control supplies available and 0% for having all child care guidelines. Health worker performance was categorised as acceptable in only 6% of cases related to sick-child assessments, 38% related to medical treatment for the given diagnosis and 33% related to patient counselling on how to administer the prescribed drugs. Best performance was recorded for availability of in-service training and supervision, for seven and ten states, respectively. Despite ongoing instability, the Ministry of Health developed capacity to use LQAS for measuring quality of care nationally and state-by-state, which will support efficient and equitable resource allocation. Overall, our data revealed a desperate need for improving the quality of care in all states.

SummaryBackgroundWe aimed to estimate socioeconomic disparities in the incidence of hospitalisation for first-ever stroke, quality of care, and post-stroke survival for the adult population of England.MethodsIn this cohort study, we obtained data collected by a nationwide register on patients aged 18 years or older hospitalised for first-ever acute ischaemic stroke or primary intracerebral haemorrhage in England from July 1, 2013, to March 31, 2016. We classified socioeconomic status at the level of Lower Super Output Areas using the Index of Multiple Deprivation, a neighbourhood measure of deprivation. Multivariable models were fitted to estimate the incidence of hospitalisation for first stroke (negative binomial), quality of care using 12 quality metrics (multilevel logistic), and all-cause 1 year case fatality (Cox proportional hazards).FindingsOf the 43·8 million adults in England, 145 324 were admitted to hospital with their first-ever stroke: 126 640 (87%) with ischaemic stroke, 17 233 (12%) with intracerebral haemorrhage, and 1451 (1%) with undetermined stroke type. We observed a socioeconomic gradient in the incidence of hospitalisation for ischaemic stroke (adjusted incidence rate ratio 2·0, 95% CI 1·7–2·3 for the most vs least deprived deciles) and intracerebral haemorrhage (1·6, 1·3–1·9). Patients from the lowest socioeconomic groups had first stroke a median of 7 years earlier than those from the highest (p<0·0001), and had a higher prevalence of pre-stroke disability and diabetes. Patients from lower socioeconomic groups were less likely to receive five of 12 care processes but were more likely to receive early supported discharge (adjusted odds ratio 1·14, 95% CI 1·07–1·22). Low socioeconomic status was associated with a 26% higher adjusted risk of 1-year mortality (adjusted hazard ratio 1·26, 95% CI 1·20–1·33, for highest vs lowest deprivation decile), but this gradient was largely attenuated after adjustment for the presence of pre-stroke diabetes, hypertension, and atrial fibrillation (1·11, 1·05–1·17).InterpretationWide socioeconomic disparities exist in the burden of ischaemic stroke and intracerebral haemorrhage in England, most notably in stroke hospitalisation risk and case fatality and, to a lesser extent, in the quality of health care. Reducing these disparities requires interventions to improve the quality of acute stroke care and address disparities in cardiovascular risk factors present before stroke.FundingNHS England and the Welsh Government.

This study aimed to characterize the quality of child health care and explore its relationship with municipal characteristics. Using data from the external assessment of the first cycle of the Brazilian National Program for Access and Quality Improvement in Primary Care (PMAQ-AB, acronym in Portuguese), this cross-sectional study evaluated 16,566 Family Health Strategy teams. In total, nine binary indicators were created based on recommendations from the Brazilian Ministry of Health. We employed latent class analysis and multinomial logistic regression to assess the quality of care and its association with region and the Brazilian Deprivation Index. Three patterns of quality of care were identified: high, intermediate, and low adequacy. The “high adequacy” pattern included 22.5% of teams, “intermediate adequacy” 60.2%, and “low adequacy” only 17.3%. Teams in the Northeast Region were over twice as likely to belong to the “high adequacy” pattern (OR = 2.34; 95%CI: 1.15-4.76) compared with those in the Central-West Region. For teams located in municipalities with moderate and low deprivation, the chance of belonging to the “high adequacy” pattern was 2.04 (95%CI: 1.44-2.89) and 9.08 (95%CI: 4.54-18.14) times higher, respectively, compared with the high deprivation municipalities. This study identified three patterns of quality of child care, with most teams characterized by an “intermediate adequacy” pattern. The quality of care was associated with the municipality’s characteristics. The methodology used in this study proved effective in characterizing the quality of care in a more consistent way.

Aligning Healthcare Safety and Quality Competencies: Quality and Safety Education for Nurses (QSEN), The Joint Commission, and American Nurses Credentialing Center (ANCC) Magnet® Standards Crosswalk

To construct and validate an indicator for evaluating the quality of care for femoral fractures, and to assess the contribution of the quality of health care as a determinant of partial permanent inability secondary to femoral fractures due to occupational accidents. The study was conducted from January to December 1995 at Mexican Institute of Social Security. The instrument was designed with experts' contribution along different stages and validated using implicit criteria and factorial analysis. A case-control study was then conducted to evaluate the contribution of the quality of care to inability secondary to femoral fractures. Cases were 108 active workers with permanent inability secondary to femoral fracture; controls were 94 active workers with fracture of femur but no permanent inability. Logistic regression modeling was used to establish the association between quality of care and partial permanent inability, adjusting by relevant variables. The ultimate indicator of quality of care consisted of the following: Timely care, presurgical management, surgical management, and fracture complications. A final score over 229 points meant that the worker had received good quality of care. Workers getting 229 or less points had received poor quality of care. Forty-eight (44%) cases and 66 (70%) controls received good quality of medical care. The likelihood of partial permanent inability was almost three times higher among workers given poor quality of care (OR 2.95; 95% CI 1.5-5.5). According to the multivariate model, predictors of partial permanent inability were: Having exposed or epiphysiary fractures, being re-submitted to surgery, having less than 90 days of rehabilitation care, and receiving deficient medical care. The constructed instrument was validated. The level of the quality of care received by workers is a determining factor for the generation of partial permanent inability. In workers having femoral fractures, it is important to consider timely medical care and early rehabilitation, to reduce the high incidence and prevalence of this medical problem in Mexico. The English version of this paper is available too at: http://www.insp.mx/salud/index.html.

This paper presents, as part of a larger mixed-methods design, a study generating a theoretical understanding of issues pertinent to the quality of mental health care in the KSA from the perspective of those using services. Semi-structured interviews were undertaken with thirty service users admitted to inpatient psychiatric wards, using an interview guide developed by the researchers, based on relevant literature. Findings from the thematic analysis showed five themes: (1) The hospital as a prison: a custody versus care dilemma, (2) quality of interactions between staff and service users, (3) quality of services, (4) staff qualities and (5) suggestions for achieving quality of care. A theoretical model drawing upon Donabedian Health Care Model for Evaluating quality of care and the Andersen Behavioural Model of Health Service Use is evident from the data. Structural aspects of care include staff experience and qualifications and key enablers around social and financial support, service users' health needs and status and the physical infrastructure and ward rules. These drive processes of care based upon robust rates of interaction between staff and service users and appear central to quality of mental health care in KSA. Quality of mental health care in KSA is manifested by a therapeutic ethos with a high degree of interaction between professional carers and service users, with the former being highly educated, competent, compassionate, with a high degree of self-awareness, and specialized in mental health. We have uncovered elements of Fanon and Azoulay's 'Cultural Originality' as well as contemporary examples of Goffman's mortification of the self.

Pay-for-performance (P4P) programmes to incentivise health providers to improve quality of care have been widely implemented globally. Despite intuitive appeal, evidence on the effectiveness of P4P is mixed, potentially due to differences in how schemes are designed. We exploited municipality variation in the design features of Brazil's National Programme for Improving Primary Care Access and Quality (PMAQ) to examine whether performance bonuses given to family health team workers were associated with changes in the quality of care and whether the size of bonus mattered. For this quasi-experimental study, we used a difference-in-differences approach combined with matching. We compared changes over time in the quality of care delivered by family health teams between (bonus) municipalities that chose to use some or all of the PMAQ money to provide performance-related bonuses to team workers with (nonbonus) municipalities that invested the funds using traditional input-based budgets. The primary outcome was the PMAQ score, a quality of care index on a scale of 0 to 100, based on several hundred indicators (ranging from 598 to 660) of health care delivery. We did one-to-one matching of bonus municipalities to nonbonus municipalities based on baseline demographic and economic characteristics. On the matched sample, we used ordinary least squares regression to estimate the association of any bonus and size of bonus with the prepost change over time (between November 2011 and October 2015) in the PMAQ score. We performed subgroup analyses with respect to the local area income of the family health team. The matched analytical sample comprised 2,346 municipalities (1,173 nonbonus municipalities; 1,173 bonus municipalities), containing 10,275 family health teams that participated in PMAQ from the outset. Bonus municipalities were associated with a 4.6 (95% CI: 2.7 to 6.4; p < 0.001) percentage point increase in the PMAQ score compared with nonbonus municipalities. The association with quality of care increased with the size of bonus: the largest bonus group saw an improvement of 8.2 percentage points (95% CI: 6.2 to 10.2; p < 0.001) compared with the control. The subgroup analysis showed that the observed improvement in performance was most pronounced in the poorest two-fifths of localities. The limitations of the study include the potential for bias from unmeasured time-varying confounding and the fact that the PMAQ score has not been validated as a measure of quality of care. Performance bonuses to family health team workers compared with traditional input-based budgets were associated with an improvement in the quality of care.

Tuberculosis (TB) remains a major global public-health problem. TB prevention and control measures are compromised by poor quality of care delivered to TB patients in health facilities during diagnosis, treatment, and follow-up; thus, this study was intended to determine the quality of TB care and treatment delivered in public-health facilities in Northeast Ethiopia. A cross-sectional study was conducted in health facilities in South Wollo zone from January to April 2018. Data were collected from each study participant through face-to-face interviews. A TB registration logbook was reviewed for every registered TB patient and compiled using a structured questionnaire and standard checklists. The quality of care for each health facility was graded as very good, good, marginal, poor, and very poor if health facilities achieved [90–100%], [80–90%), [70–80%), [60–70%), and <60% of performance indicators, respectively, using the Donabedian structure, process, and outcome model of healthcare quality. All the health facilities had at least one functional microscope, and all the facilities had sufficient TB drugs almost all the time. All the facilities had reported to have sufficient laboratory reagents and slides for sputum smear microscopy. Of 1579 patients registered, 18.5% and 66.1% were cured and successfully completed the course of treatment, respectively. The overall quality of TB care and treatment was good (72.5%), and ranged from 70.9% to 74.8% among health facilities. Outcome (83.4%) and process (80%) qualities of care were very good but the structural quality of care was very poor. In conclusion, the overall quality of TB care and treatment analysed in this study was found to be good. There should be an integrated approach to improve the quality of TB care and treatment in health facilities in Ethiopia. Based on the findings, continuous supply of anti-TB drugs, laboratory equipment and reagents, availing current guidelines, providing up to-date training for healthcare workers, and proper documentation are important to improve the quality of care delivered to TB patients.

This paper deals with the some of the important variable factors relating to health care in Saudi Arabia, with special emphasis on primary health. Other aspects considered are the financial influen...