Patient issues in health research and quality of care: an inventory and data synthesis

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.

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

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.

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

Creating an ideal system of care to address the care forpatients with ST-elevation myocardial infarction (STEMI) iscomplex from both the system’s and patient/family’s perspec-tives. In general, this care is unlike most other hospital care.It typically involves very fast and complex decision makingand, often, sudden transportation to another facility forpercutaneous coronary intervention (PCI). All of this occurswith a potentially critically ill patient and at a time when thefamily is often not immediately available. In this report, weaddress key perspectives from the patient and public point ofview of the current system of care for STEMI patients andhighlight the barriers and gaps that must be addressed by anideal system of care (Table 1).

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.

BackgroundThe COVID-19 pandemic has sharpened the focus on health care safety and quality, underscoring the importance of using standardized metrics such as the International Classification of Diseases, Tenth Revision (ICD-10). In this regard, the ICD-10 cluster Y62-Y69 serves as a proxy assessment of safety and quality in health care systems, allowing researchers to evaluate medical misadventures. Thus far, extensive research and reports support the need for more attention to safety and quality in health care. The study aims to leverage the pandemic’s unique challenges to explore health care safety and quality trends during prepandemic, intrapandemic, and postpandemic phases, using the ICD-10 cluster Y62-Y69 as a key tool for their evaluation.ObjectiveThis research aims to perform a comprehensive retrospective analysis of incidence rates associated with ICD-10 cluster Y62-Y69, capturing both linear and nonlinear trends across prepandemic, intrapandemic, and postpandemic phases over an 8-year span. Therefore, it seeks to understand how these trends inform health care safety and quality improvements, policy, and future research.MethodsThis study uses the extensive data available through the TriNetX platform, using an observational, retrospective design and applying curve-fitting analyses and quadratic models to comprehend the relationships between incidence rates over an 8-year span (from 2015 to 2023). These techniques will enable the identification of nuanced trends in the data, facilitating a deeper understanding of the impacts of the COVID-19 pandemic on medical misadventures. The anticipated results aim to outline complex patterns in health care safety and quality during the COVID-19 pandemic, using global real-world data for robust and generalizable conclusions. This study will explore significant shifts in health care practices and outcomes, with a special focus on geographical variations and key clinical conditions in cardiovascular and oncological care, ensuring a comprehensive analysis of the pandemic’s impact across different regions and medical fields.ResultsThis study is currently in the data collection phase, with funding secured in November 2023 through the Ricerca Corrente scheme of the Italian Ministry of Health. Data collection via the TriNetX platform is anticipated to be completed in May 2024, covering an 8-year period from January 2015 to December 2023. This dataset spans pre-pandemic, intra-pandemic, and early post-pandemic phases, enabling a comprehensive analysis of trends in medical misadventures using the ICD-10 cluster Y62-Y69. The final analytics are anticipated to be completed by June 2024. The study's findings aim to provide actionable insights for enhancing healthcare safety and quality, reflecting on the pandemic's transformative impact on global healthcare systems.ConclusionsThis study is anticipated to contribute significantly to health care safety and quality literature. It will provide actionable insights for health care professionals, policy makers, and researchers. It will highlight critical areas for intervention and funding to enhance health care safety and quality globally by examining the incidence rates of medical misadventures before, during, and after the pandemic. In addition, the use of global real-world data enhances the study’s strength by providing a practical view of health care safety and quality, paving the way for initiatives that are informed by data and tailored to specific contexts worldwide. This approach ensures the findings are applicable and actionable across different health care settings, contributing significantly to the global understanding and improvement of health care safety and quality.International Registered Report Identifier (IRRID)PRR1-10.2196/54838

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.

Patient perceptions of quality of care (QoC) are directly linked with patient safety and clinical effectiveness. We need patient-designed QoC instruments that work across languages and countries to optimise studies across systems in this area. Few QoC measurement tools exist that assess all aspects of QoC from the patient perspective. This paper describes the development and validation of a comprehensive measure to assess patient perceptions of QoC that incorporates technical and interpersonal aspects of care and is grounded in the established Institute of Medicine (IOM) QoC framework. We conducted a multi-country cross-sectional study. Following a literature review and patient focus groups, an expert panel generated questionnaire items. Following a pilot study, item numbers were reduced. The final questionnaire consisted of three sections: demographics, perceived QoC and one open-ended question. Data was collected from patients (n=531) discharged from hospitals across seven countries in South East Europe (languages: Turkish, Greek, Portuguese, Romanian, Croatian, Macedonian and Bulgarian). Reliability and validity of the measure were assessed. Confirmatory factor analysis was used to compare various factor models of patient-perceived QoC. Good model fit was demonstrated for a two-factor model: communication and interpersonal care, and hospital facilities. The ORCAB (Improving quality and safety in the hospital: The link between organisational culture, burnout and quality of care) Patient QoC questionnaire has been collaboratively and exhaustively developed between healthcare professionals and patients. It enables patient QoC data to be assessed in the context of the IOM pillars of quality, considering both technical and interpersonal dimensions of care. It represents an important first step in including the patient perspective.

Background Many adults suffer from an array of consequences due to their hearing loss (e.g., self-efficacy, mastery, psychosocial challenges). Family involvement can help improve their outcomes. Purpose This study aimed to determine audiology adult patients hearing experiences and inquired about their perspectives on family involvement in appointments. Research Design A cross-sectional survey was completed. Descriptive statistics, item analyses, and quantitative analyses were used to examine patient's characteristics and perspectives. Study Sample Three hundred eighty-two adult audiology patients participated in the study. Data Collection and Analysis A 15-item survey was created with 4 sections, including patient demographic information, general hearing questions, hearing experiences, and family interactions and involvement. Descriptive statistics were used to examine patient's characteristics and perspectives on family involvement in audiology appointments. Chronbach's alpha was used to reveal good internal consistency of difficult feelings related to hearing and perceived negative family member reactions. Quantitative analyses were used to determine patient perspectives on family involvement. Results Though patients reported difficulties due to their hearing loss, more than half reported that they did not want family involvement or they were unsure of the benefit that the involvement would provide. Patients who were interested in having family involved reported benefits such as educational opportunities and support. Few barriers of family involvement were reported by patients. Conclusions Patients had a mixed desire about family involvement in their adult audiology appointments. Education of patients about the benefits of family involvement may need to happen for this shift in audiologic practice.

Background Seven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of the day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units. Objectives To investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units, and to identify factors influencing such variations. Design This was a prospective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme. Factors influencing variations in care and outcomes were studied through interview and observation data. Setting The setting was acute stroke services in London hyperacute stroke units. Participants A total of 7094 patients with a primary diagnosis of stroke took part. We interviewed hyperacute stroke unit staff (n = 76), including doctors, nurses, therapists and administrators, and 31 patients and carers. We also conducted non-participant observations of delivery of care at different times of the day and week (n = 45, ≈102 hours). Intervention Hub-and-spoke model for care of suspected acute stroke patients in London with performance standards was designed to deliver uniform access to high-quality hyperacute stroke unit care across the week. Main outcome measures Indicators of quality of acute stroke care, mortality at 3 days after admission, disability at the end of the inpatient spell and length of stay. Data sources Sentinel Stroke National Audit Programme data for all patients in London hyperacute stroke units with a primary diagnosis of stroke between 1 January and 31 December 2014, and nurse staffing data for all eight London hyperacute stroke units for the same period. Results We found no variation in quality of care by day and time of admission across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor in 3-day mortality nor disability at hospital discharge. Other quality-of-care measures significantly varied by day and time of admission. Quality of care was better if the nurse in charge was at a higher band and/or there were more nurses on duty. Staff deliver ‘front-door’ interventions consistently by taking on additional responsibilities out of hours, creating continuities between day and night, building trusting relationships and prioritising ‘front-door’ interventions. Limitations We were unable to measure long-term outcomes as our request to the Sentinel Stroke National Audit Programme, the Healthcare Quality Improvement Partnership and NHS Digital for Sentinel Stroke National Audit Programme data linked with patient mortality status was not fulfilled. Conclusions Organisational factors influence 24 hours a day, 7 days a week (24/7), provision of stroke care, creating temporal patterns of provision reflected in patient outcomes, including mortality, length of stay and functional independence. Future work Further research would help to explore 24/7 stroke systems in other contexts. We need a clearer understanding of variations by looking at absolute time intervals, rather than achievement of targets. Research is needed with longer-term mortality and modified Rankin Scale data, and a more meaningful range of outcomes. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 34. See the NIHR Journals Library website for further project information.

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.

New evidence on the quality of health care from public services in Niger is discussed in terms of the relationships between quality, costs, cost-effectiveness and financing. Although structural attributes of quality appeared to improve with the pilot project in Niger, significant gaps in the implementation of diagnostic and treatment protocols were observed, particularly in monitoring vital signs, diagnostic examination and provider-patient communications. Quality improvements required significant investments in both fixed and variable costs; however, many of these costs were basic input requirements for operation. It is likely that optimal cost-effectiveness of services was not achieved because of the noted deficiencies in quality. In the test district of Boboye, the revenues from the copayments alone covered about 34% of the costs of medicines or about 20% of costs of drugs and administration. In Say, user fees covered about 50-55% of the costs of medicines or 35-40% of the amount spent on medicines and cost-recovery administration. In Boboye, taxes plus the additional copayments covered 120-180% of the cost of medicines, or 75-105% of the cost of medicines plus administration of cost recovery. Decentralized management and legal conditions in the pilot districts appeared to provide the necessary structure to ensure that the revenues and taxes collected would be channelled to pay for quality improvements.

We often use the term patient-centered care to describe health care services delivered to patients and families. Individualized care based on the unique needs of patients and families is a core value of nurses and likely would be identified similarly by other types of health care providers as well. Yet, the notion of patient-centered care seems to be lacking in many practice environments today. This has important implications for both nursing practice and research. At a system level, it has been acknowledged that patient-centered care is an aspiration, not a reality. An Institute of Medicine report defined patient-centered care as one of six dimensions central to the redesign of the health care system needed in the 21st century. It is a dimension identified as lacking in our current system. The report defines patient-centered as ". . . providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions" (Committee on Quality of Health Care in America, 2001, p. 6). At a more local level, examples of the lack of patient-centered care experienced by family members, friends, or perhaps even ourselves, often exist. Donald Berwick, the prominent physician founder of the Institute for Healthcare Improvement and a national leader in patient safety and quality of care, discusses the situation faced when his wife was hospitalized with a serious illness. He describes how they expected to receive patient-centered care but found themselves caught in ". . . a tangle of onerous rules and assaults on our dignity, and we found our caregivers too often more interested in explaining how something must be done instead of asking us how we needed it to be done" (Berwick, 2004, p. 219). The Picker/Commonwealth Program for Patient-Centered Care conducted a study to identify patients' experiences with and preferences for the health care system. It conducted focus groups and interviews with more than 6,000 patients and 2,000 family members within 6 months of a hospitalization. Seven dimensions of patient-centered care were identified to define what patients said would make care centered on their needs. These dimensions are respect for patients' values, preferences, and expressed needs; physical comfort; emotional support; coordination and integration of care; involvement of family and friends in communication about their health status; frequent information, communication, and education about their condition; and transition and continuity (Gerteis, Edgman-Levitan, Daley, & Delbanco, 1993). These findings provide important benchmarks for examining whether care delivered is patient-centered and, if not, where improvements might be needed in the practice environment. Challenges for patient-centeredness also exist when research is conducted as well. In many research investigations, patients are asked to offer their assessments of treatment in terms of its impact on health-related quality of life or health status. …

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.