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Background: Patient reported outcome measures (PROMs) can be used by healthcare organisations to inform improvements in service delivery. However, routine collection of PROMs is difficult to achieve across an entire healthcare organisation. An understanding of the use of PROMs within an organisation can provide valuable insights on the purpose, scope and practical considerations of PROMs collection, which can inform implementation of PROMs. Methods: We used multiple research methods to assess the use of PROMs in research projects, data registries and clinical care across a healthcare organisation from January 2014 to April 2021. The methods included an audit of ethics applications approved by the organisation's human research ethics committee and registries which the health organisation had contributed data to; a literature review of peer-reviewed journal articles reporting on research projects conducted at the organisation; and a survey of health professionals use of PROMs in research projects, data registries and clinical care. The scope of PROMs was determined by classifying PROMs as either 'specific' to a particular disease and/or condition, or as a 'generic' measure with further classification based on the health domains they measured, using the World Health Organization International Classification Framework. Practical considerations included mode and timing of PROMs administration. Data were described using frequency and proportion. Results: PROMs were used by 22% of research projects (n = 144/666), 68% of data registries (n = 13/19), and 76% of clinical specialties in their clinical care (n = 16/21). Disease specific PROMs were most commonly used: 83% of research projects (n = 130/144), 69% of clinical registries (n = 9/13), and 75% of clinical specialties (n = 12/16). Greater than 80% of research projects, clinical registries and clinical specialties measured health domains relating to both body impairments and participation in daily life activities. The most commonly used generic PROM was the EQ-5D (research projects n = 56/144, 39%; data registries n = 5/13, 38%; clinical specialties n = 4/16, 25%). PROMs used in clinical care were mostly paper-based (n = 47/55, 85%). Conclusions: We have elicited information on the use of PROMs to inform a health organisation wide implementation strategy. Future work will determine clinician and patient acceptability of the EQ-5D, and co-design a system for the collection of PROMs. [ABSTRACT FROM AUTHOR]

Background: Prior literature identified the use of Performance Measurement Systems (PMS) as crucial in addressing improved processes of care. Moreover, a strategic use of PMS has been found to enhance quality, compared to non-strategic use, although a clear understanding of this linkage is still to be achieved. This paper deals with the test of direct and indirect models related to the link between the strategic use of PMS and the level of improved processes in health care organizations. Indirect models were mediated by the degree of perceived managerial discretion.Methods: A PLS analysis on a survey of 97 Italian managers working for health care organizations in the Lombardy region was conducted. The response rate was 77.6%.Results: The strategic use of PMS in health care organizations directly and significantly (p < 0.001) enhances performance in terms of improved processes. Perceived managerial discretion is positively and significantly (p < 0.001) affected by the strategic use of PMS, whereas the mediation effect is non-significant.Conclusions: This study contributes to the literature investigating the design and implementation of a non-financial measurement tool, such as the non-financial information included into a balanced scorecard (BSC), in health care organizations. Managers in health care organizations can benefit from the strategic use of PMS to effectively allocate their time to strategic opportunities and threats, which might arise and affect organizational, output-related performance, such as improving processes. [ABSTRACT FROM AUTHOR]

Background: Strong relations between medicine and public health have long been advocated. Today, professional medical practice assumes joint clinical/public health objectives: GPs are expected to practice community medicine; Hospital specialists can be involved in disease control and health service organisation; Doctors can teach, coach, evaluate, and coordinate care; Clinicians should interpret protocols with reference to clinical epidemiology. Public health physicians should tailor preventive medicine to individual health risks. This paper is targeted at those practitioners and academics responsible for their teams' professionalism and the accessibility of care, where the authors argue in favour of the epistemological integration of clinical medicine and public health.Main Text: Based on empirical evidence the authors revisit the epistemological border of clinical and public health knowledge to support joint practice. From action-research and cognitive psychology, we derive clinical/public health knowledge categories that require different transmission and discovery techniques. The knowledge needed to support the universal human right to access professional care bridges both clinical and public health concepts, and summons professional ethics to validate medical decisions. To provide a rational framework for teaching and research, we propose the following categories: 'Know-how/practice techniques', corresponding a.o. to behavioural, communication, and manual skills; 'Procedural knowledge' to choose and apply procedures that meet explicit quality criteria; 'Practical knowledge' to design new procedures and inform the design of established procedures in new contexts; and Theoretical knowledge teaches the reasoning and theory of knowledge and the laws of existence and functioning of reality to validate clinical and public health procedures. Even though medical interventions benefit from science, they are, in essence, professional: science cannot standardise eco-biopsychosocial decisions; doctor-patient negotiations; emotional intelligence; manual and behavioural skills; and resolution of ethical conflicts.Conclusion: Because the quality of care utilises the professionals' skill-base but is also affected by their intangible motivations, health systems should individually tailor continuing medical education and treat collective knowledge management as a priority. Teamwork and coaching by those with more experience provide such opportunities. In the future, physicians and health professionals could jointly develop clinical/public health integrated knowledge. To this end, governments should make provision to finance non-clinical activities. [ABSTRACT FROM AUTHOR]

Background Internationally, key health care reform elements rely on improved integration of care between the primary and secondary sectors. The objective of this systematic review is to synthesise the existing published literature on elements of current integrated primary/secondary health care. These elements and how they have supported integrated healthcare governance are presented. Methods A systematic review of peer-reviewed literature from PubMed, MEDLINE, CINAHL, the Cochrane Library, Informit Health Collection, the Primary Health Care Research and Information Service, the Canadian Health Services Research Foundation, European Foundation for Primary Care, European Forum for Primary Care, and Europa Sinapse was undertaken for the years 2006-2012. Relevant websites were also searched for grey literature. Papers were assessed by two assessors according to agreed inclusion criteria which were published in English, between 2006-2012, studies describing an integrated primary/secondary care model, and had reported outcomes in care quality, efficiency and/or satisfaction. Results Twenty-one studies met the inclusion criteria. All studies evaluated the process of integrated governance and service delivery structures, rather than the effectiveness of services. They included case reports and qualitative data analyses addressing policy change, business issues and issues of clinical integration. A thematic synthesis approach organising data according to themes identified ten elements needed for integrated primary/secondary health care governance across a regional setting including: joint planning; integrated information communication technology; change management; shared clinical priorities; incentives; population focus; measurement - using data as a quality improvement tool; continuing professional development supporting joint working; patient/community engagement; and, innovation. Conclusions All examples of successful primary/secondary care integration reported in the literature have focused on a combination of some, if not all, of the ten elements described in this paper, and there appears to be agreement that multiple elements are required to ensure successful and sustained integration efforts. Whilst no one model fits all systems these elements provide a focus for setting up integration initiatives which need to be flexible for adapting to local conditions and settings. [ABSTRACT FROM AUTHOR]

Background: Hospital governance is broadening its orientation from cost and production controls towards 'improving performance on clinical outcomes'. Given this new focus one might assume that doctors are drawn into hospital management across OECD countries. Hospital performance in terms of patient health, quality of care and efficiency outcomes is supposed to benefit from their involvement. However, international comparative evidence supporting this idea is limited. Just a few studies indicate that there may be a positive relationship between medical doctors being part of hospital boards, and overall hospital performance. More importantly, the assumed relationship between these so-called doctor managers and hospital performance has remained a 'black-box' thus far. However, there is an increasing literature on the implementation of quality management systems in hospitals and their relation with improved performance. It seems therefore fair to assume that the relation between the involvement of doctors in hospital management and improved hospital performance is partly mediated via quality management systems. The threefold aim of this paper is to 1) perform a quick scan of the current situation with regard to doctor managers in hospital management in 19 OECD countries, 2) explore the phenomenon of doctor managers in depth in 7 OECD countries, and 3) investigate whether doctor involvement in hospital management is associated with more advanced implementation of quality management systems.Methods: This study draws both on a quick scan amongst country coordinators in OECD's Health Care Quality Indicator program, and on the DUQuE project which focused on the implementation of quality management systems in European hospitals.Results: This paper reports two main findings. First, medical doctors fulfil a broad scope of managerial roles at departmental and hospital level but only partly accompanied by formal decision making responsibilities. Second, doctor managers having more formal decision making responsibilities in strategic hospital management areas is positively associated with the level of implementation of quality management systems.Conclusions: Our findings suggest that doctors are increasingly involved in hospital management in OECD countries, and that this may lead to better implemented quality management systems, when doctors take up managerial roles and are involved in strategic management decision making. [ABSTRACT FROM AUTHOR]

Background: This paper critically reviews published tools and indicators currently used to measure maternity care performance within Europe, focusing particularly on whether and how current approaches enable systematic appraisal of processes of minimal (or non-) intervention in support of physiological or "normal birth". The work formed part of COST Actions IS0907: "Childbirth Cultures, Concerns, and Consequences: Creating a dynamic EU framework for optimal maternity care" (2011-2014) and IS1405: Building Intrapartum Research Through Health - an interdisciplinary whole system approach to understanding and contextualising physiological labour and birth (BIRTH) (2014-). The Actions included the sharing of country experiences with the aim of promoting salutogenic approaches to maternity care.Methods: A structured literature search was conducted of material published between 2005 and 2013, incorporating research databases, published documents in english in peer-reviewed international journals and indicator databases which measured aspects of health care at a national and pan-national level. Given its emergence from two COST Actions the work, inevitably, focused on Europe, but findings may be relevant to other countries and regions.Results: A total of 388 indicators were identified, as well as seven tools specifically designed for capturing aspects of maternity care. Intrapartum care was the most frequently measured feature, through the application of process and outcome indicators. Postnatal and neonatal care of mother and baby were the least appraised areas. An over-riding focus on the quantification of technical intervention and adverse or undesirable outcomes was identified. Vaginal birth (no instruments) was occasionally cited as an indicator; besides this measurement few of the 388 indicators were found to be assessing non-intervention or "good" or positive outcomes more generally.Conclusions: The tools and indicators identified largely enable measurement of technical interventions and undesirable health (or pathological medical) outcomes. A physiological birth generally necessitates few, or no, interventions, yet most of the indicators presently applied fail to capture (a) this phenomenon, and (b) the relationship between different forms and processes of care, mode of birth and good or positive outcomes. A need was identified for indicators which capture non-intervention, reflecting the reality that most births are low-risk, requiring few, if any, technical medical procedures. [ABSTRACT FROM AUTHOR]

Background: The promotion of care pathways in the recent Governmental health policy reports of Lord Darzi is likely to increase efforts to promote the use of care pathways in the NHS. Evidence on the process of pathway implementation, however, is sparse and variations in how organisations go about the implementation process are likely to be large. This paper summarises what is known about factors which help or hinder clinicians in adopting and putting care pathways into practice, and which consequently promote or hinder the implementation of scientific evidence in clinical practice. Discussion: Care pathways can provide patients with clear expectations of their care, provide a means of measuring patient's progress, promote teamwork on a multi-disciplinary team, facilitate the use of guidelines, and may act as a basis for a payment system. In order to achieve adequate implementation, however, facilitators and barriers must be considered, planned for, and incorporated directly into the pathway with full engagement among clinical and management staff. Barriers and/or facilitators may be present at each stage of development, implementation and evaluation; and, barriers at any stage can impede successful implementation. Important considerations to be made are ensuring the inclusion of all types of staff, plans for evaluating and incorporating continuous improvements, allowing for organisational adaptations and promoting the use of multifaceted interventions. Summary: Although there is a dearth of information regarding the successful implementation of care pathways, evidence is available which may be applied when implementing a care pathway. Multifaceted interventions which incorporate all staff and facilitate organisational adaptations must be seriously considered and incorporated alongside care pathways in a continuous manner. In order to better understand the mechanism upon which care pathways are effective, however, more research specifically addressing conditions under which providers become engaged in using care pathways is needed. [ABSTRACT FROM AUTHOR]

Background: The aim of Clinical Governance (CG) is to the pursuit of quality in health care through the integration of all the activities impacting on the patient into a single strategy. OPTIGOV (Optimizing Health Care Governance) is a methodology for the assessment of the level of implementation of CG within healthcare organizations. The aim of this paper is to explain the process underlying the development of OPTIGOV, and describe its characteristics and steps. Methods: OPTIGOV was developed in 2006 by the Institute of Hygiene of the Catholic University of the Sacred Heart and Eurogroup Consulting Alliance. The main steps of the process were: choice of areas for analysis and questionnaire development, based on a review of scientific literature; assignment of scores and weights to individual questions and areas; implementation of a software interfaceable with Microsoft Office. Results: OPTIGOV consists of: a) a hospital audit with a structured approach; b) development of an improvement operational plan. A questionnaire divided into 13 areas of analysis is used. For each area there is a form with a variable number of questions and "closed" answers. A score is assigned to each answer, area of analysis, healthcare department and unit. The single scores can be gathered for the organization as a whole. The software application allows for collation of data, calculation of scores and development of benchmarks to allow comparisons between healthcare organizations. Implementation consists of three stages: the preparation phase includes a kick off meeting, selection of interviewees and development of a survey plan. The registration phase includes hospital audits, reviewing of hospital documentation, data collection and score processing. Lastly, results are processed, inserted into a final report, and discussed in a meeting with the Hospital Board and in a final workshop. Conclusions: The OPTIGOV methodology for the evaluation of CG implementation was developed with an evidencebased approach. The ongoing adoption of OPTIGOV in several projects will put to the test its potential to realistically represent the organization status, pinpoint criticalities and transferable best practices, provide a plan for improvement, and contribute to triggering changes and pursuit of quality in health care. [ABSTRACT FROM AUTHOR]

Background: Since the early 1980s all European countries have given priority to reforming the management of health services. A distinctive feature of these reforms has also been the drive to co-opt professionals themselves into the management of services, taking on full time or part time (hybrid) management or leadership roles. However, although these trends are well documented in the literature, our understanding of the nature and impact of reforms and how they are re-shaping the relationship between medicine and management remains limited. Most studies have tended to be nationally specific, located within a single discipline and focused primarily on describing new management practices. This article serves as an Introduction to a special issue of BMC Health Services Research which seeks to address these concerns. It builds on the work of a European Union funded COST Action (ISO903) which ran between 2009 and 2013, focusing specifically on the changing relationship between medicine and management in a European context., Main Text: Prior to describing the contributions to the special issue, this Introduction sets the scene by exploring four main questions which have characterised much of the recent literature on medicine and management. First is the question of what we understand by the changing relationship between medicine and management and in particular which this means for the emergence of so called 'hybrid' clinical leader roles? A second question concerns the forces that have driven change, in particular those relating to the wider project of management reforms. Third, we raise questions of how medical professionals have responded to these changes and what factors have shaped their responses. Lastly we consider what some of the outcomes of greater medical involvement in management and leadership might be, both in terms of intended and unintended outcomes., Conclusions: The paper concludes by summarising the contributions to the special issue and highlighting the need to extend research in this area by focusing more on comparative dimensions of change. It is argued that future research would also benefit theoretically by drawing together insights from health policy and management literatures.

Background: Despite the complexity of drug use, a number of indicators have been developed, standardized and evaluated by the World Health Organization (WHO). These indicators are grouped in to three categories namely: prescribing indicators, patient care indicators and facility indicators. The study was aimed to evaluate rational drug use based on WHO-core drug use indicators in Dilchora referral hospital, Dire Dawa; Hiwot Fana specialized university hospital, Harar and Karamara general hospital, Jigjiga, eastern Ethiopia.Methods: Hospital based quantitative cross sectional study design was employed to evaluate rational drug use based on WHO core drug use indicators in selected hospitals. Systematic random sampling for prescribing indicators and convenient sampling for patient care indicators was employed. Taking WHO recommendations in to account, a total of 1,500 prescription papers (500 from each hospitals) were investigated. In each hospital, 200 outpatient attendants and 30 key essential drugs were also selected using the WHO recommendation. Data were collected using retrospective and prospective structured observational check list. Data were entered to EPI Data Version 3.1, exported and analyzed using SPSS version 16.0. Besides, the data were evaluated as per the WHO guidelines. Statistical significance was determined by one way analysis of variance (ANOVA) for some variables. P-value of less than 0.05 was considered statistically significant. Finally, tabular presentation was used to present the data.Results: Mean, 2.34 (±1.08) drugs were prescribed in the selected hospitals. Prescriptions containing antibiotics and that of injectables were 57.87 and 10.9% respectively. The average consultation and dispensing time were 276.5 s and 61.12 s respectively. Besides, 75.77% of the prescribed drugs were actually dispensed. Only 3.3% of prescriptions were adequately labeled and 75.7% patients know about the dosage of the prescription. Not more than, 20(66.7%) key drugs were available in stock while only 19(63.3%) of key drugs had adequate labeling. On average, selected key drugs were out of stock for 30 days per year. All of the hospitals included in the study used the national drug list, formulary and standard treatment guidelines but none of them had their own drug list or guideline.Conclusion: Majority of WHO stated core drug use indicators were not met by the three hospitals included in the study. [ABSTRACT FROM AUTHOR]

Background: The scale and scope of medical tourism have expanded rapidly over the last few decades. Turkey is becoming an important player in this market because of its relatively better service quality and large comparative cost advantage.Methods: This paper compares cost, quality and effectiveness of in-vitro fertilization (IVF) in the USA and in Turkey. The data from Turkey were obtained from a hospital specializing in IVF services and the US data came from secondary sources. Package price offered by the dominant IVF-service provider to international patients in Turkey was used as a measure of cost for Turkey while IVF-specific service prices were used to estimate the cost for USA. To compare quality and effectiveness of IVF services, a number of general clinical quality indicators and IVF success rate were used.Results: Indicators of quality, cost and success rate in the Turkish hospital were found to be better than the corresponding indicators in US hospitals. The cost difference of IVF services between USA and Turkey is so significant that the overall cost of obtaining the service from Turkey remains lower even with additional expenses for travel and accommodation.Conclusions: Cost-effectiveness ratio of IVF treatment per successful clinical pregnancy was much lower in Turkey than in the USA. It appears that cost and quality are the two most important factors affecting demand for health care services by international patients in Turkey. Like other important players in the medical tourism market, Turkey should be able to take advantage of its success in IVF, a highly specialized niche market, to transform its health system into an important exporter of general health services. [ABSTRACT FROM AUTHOR]

Background The primary care sector represents the linchpin of many health systems. However, the translation of evidence-based practices into patient care can be difficult, particularly during healthcare reform. This can have significant implications for patients, their communities, and the public purse. This is aptly demonstrated in the area of sexual health. The aim of this paper is to determine what works to facilitate evidence-based sexual healthcare within the primary care sector. Methods 431 clinicians (214 general practitioners and 217 practice nurses) in New South Wales, Australia, were surveyed about their awareness, their use, the perceived impact, and the factors that hindered the use of six resources to promote sexual healthcare. Descriptive statistics were calculated from the responses to the closed survey items, while responses to open-ended item were thematically analyzed. Results All six resources were reported to improve the delivery of evidence-based sexual healthcare. Two resources -- both double-sided A4-placards -- had the greatest reach and use. Barriers that hindered resource-use included limited time, limited perceived need, and limited access to, or familiarity with the resources. Furthermore, the reorganization of the primary care sector and the removal of particular medical benefits scheme items may have hampered clinician capacity to translate evidence-based practices into patient care. Conclusions Findings reveal: (1) the translation of evidence-based practices into patient care is viable despite reform; (2) the potential value of a multi-modal approach; (3) the dissemination of relatively inexpensive resources might influence clinical practices; and (4) reforms to governance and/or funding arrangements may widen the void between evidence-based practices and patient care. [ABSTRACT FROM AUTHOR]

Background: A plethora of clinical studies have assessed the benefits of implantable cardioverter defibrillators (ICDs) and supported their use in clinical practice. However, evidence on the safety and efficacy of ICDs appears insufficient to support expansion of their use in clinical practice, and more information on their impact in real life settings is warranted. This paper aims to investigate the impact of ICDs using a large administrative dataset reflecting actual clinical practice. Methods: Data were obtained from the hospital discharge database of the Friuli Venezia Giulia region in Italy containing patient-level information on 169,488 cases. Data on mortality outside hospital were obtained from regional sources. Exact matching method was used to estimate the outcomes associated with ICDs: mortality, length of stay, re-hospitalization and regional expenditure. The method was applied in two steps. First, patients with ICDs were matched with those without using the following: age class (by 5 years), gender, year of admission, type of admission (day hospital vs. ordinary) and primary diagnosis. In the second step, matching included also Charlson Comorbidities Index. Exact matching average treatment effect on the treated (ATT) was used as a main measure of impact. Results: Compared with matched controls, treatment with ICDs was associated with lower mortality (absolute risk reduction 10.6% at 1 year and 8.3% at 2 and 8.4% at 3 years, p < 0.001 and hazard ratio 0.80, p < 0.001), greater regional expenditure at index hospitalization (ATT: €9459.64, p < 0.001) and during follow up (ATT: €1707.29, p < 0.001) and higher re-hospitalization rate (ATT: 0.53, p < 0.001). No significant difference was found for length of stay (9.07 vs. 8.86 days). The results were maintained after more restrictive matching was applied. Conclusions: Assessing the impact of innovative, expensive medical technologies on the basis of real world data is warranted, especially when there are barriers to implementation. Hospital administrative datasets can be of great value when a technology such as the ICD is implemented in a relatively small sample of patients, to allow use of exact matching techniques. [ABSTRACT FROM AUTHOR]

Background: Tinnitus is a common chronic health condition that affects 10% to 20% of the general population. Among severe sufferers it causes disability in various areas. As a result of the tinnitus, quality of life is often impaired. At present there is no cure or uniformly effective treatment, leading to fragmentized and costly tinnitus care. Evidence suggests that a comprehensive multidisciplinary approach in treating tinnitus is effective. The main objective of this study is to examine the effectiveness, costs, and cost-effectiveness of a comprehensive treatment provided by a specialized tinnitus center versus usual care. This paper describes the study protocol. Methods/Design: In a randomized controlled clinical trial 198 tinnitus patients will be randomly assigned to a specialized tinnitus care group or a usual care group. Adult tinnitus sufferers referred to the audiological centre are eligible. Included patients will be followed for 12 months. Primary outcome measure is generic quality of life (measured with the Health Utilities Index Mark III). Secondary outcomes are severity of tinnitus, general distress, tinnitus cognitions, tinnitus specific fear, and costs. Based on health state utility outcome data the number of patients to include is 198. Economic evaluation will be performed from a societal perspective. Discussion: This is, to our knowledge, the first randomized controlled trial that evaluates a comprehensive treatment of tinnitus and includes a full economic evaluation from a societal perspective. If this intervention proves to be effective and cost-effective, implementation of this intervention is considered and anticipated. Trial Registration: The trial has been registered at ClinicalTrial.gov. The trial registration number is NCT00733044 [ABSTRACT FROM AUTHOR]

Background: Hospital care organization, structured around medical specialties and focused on the separate treatment of individual organ systems, is challenged by the increasing prevalence of multimorbidity. To support the hospitals' realization of multidisciplinary care, we hypothesized that using machine learning on clinical data helps to identify groups of medical specialties who are simultaneously involved in hospital care for patients with multimorbidity. Methods: We conducted a cross-sectional study of patients in a Dutch general hospital and used a fuzzy c-means clustering algorithm for the analysis. We explored the patients' membership degrees in each cluster to identify subgroups of medical specialties that provide care to the same patients with multimorbidity. We used retrospectively collected electronic health record data from 2017. We extracted data from 22,133 patients aged ≥18 years who had received outpatient clinical care for two or more chronic and/ or oncological diagnoses. Results: We found six clusters of medical specialties and identified 22 subgroups. The clusters were labeled based on the specialties that most characterized them: 1. dermatology/ plastic surgery, 2. six specialties (gynecology/ rheumatology/ orthopedic surgery/ urology/ gastroenterology/ otorhinolaryngology), 3. pulmonology, 4. internal medicine/ cardiology/ geriatrics, 5. neurology/ physiatry (rehabilitation)/ anesthesiology, and 6. internal medicine. Most patients had a full or dominant membership to one of these clusters of medical specialties (11 subgroups), whereas fewer patients had a membership to two clusters. The prevalence of specific diagnosis groups, patient characteristics, and healthcare utilization differed between subgroups. Conclusion: Our study shows that clusters and subgroups of medical specialties simultaneously involved in hospital care for patients with multimorbidity can be identified with fuzzy c-means cluster analysis using clinical data. Clusters and subgroups differed regarding the involved medical specialties, diagnoses, patient characteristics, and healthcare utilization. With this strategy, hospitals and medical specialists can further analyze which subgroups are target populations that might benefit from improved multidisciplinary collaboration. [ABSTRACT FROM AUTHOR]

Background: Same-day initiation (SDI) of antiretroviral therapy (ART) increases ART uptake, however retention in care after ART initiation remains a challenge. Public health behaviours, such as retention in HIV care and adherence to antiretroviral therapy (ART) pose major challenges to reducing new Human Immunodeficiency Virus (HIV) transmission and improving health outcomes among HIV patients. Methods: We evaluated 6-month retention in care, and clinical outcomes of an ART cohort comprising of SDI and delayed ART initiators. We conducted a 6 months' observational prospective cohort study of 403 patients who had been initiated on ART. A structured questionnaire was used to abstract data from patient record review which comprised the medical charts, laboratory databases, and Three Interlinked Electronic Registers.Net (TIER.Net). Treatment adherence was ascertained by patient visit constancy for the clinic scheduled visit dates. Retention in care was determined by status at 6 months after ART initiation. Results: Among the 403 participants enrolled in the study and followed up, 286 (70.97%) and 267 (66.25%) complied with scheduled clinics visits at 3 months and 6 months, respectively. One hundred and thirteen (28.04%) had been loss to follow-up. 17/403 (4.22%) had died and had been out of care after 6 months. 6 (1.49%) had been transferred to other health facilities and 113 (28.04%) had been loss to follow-up. Among those that had been lost to follow-up, 30 (33.63%) deferred SDI while 75 (66.37%) initiated ART under SDI. One hundred and eighty-nine (70.79%) participants who had remained in care were SDI patients while 78 (29.21%) were SDI deferred patients. In the bivariate analysis; gender (OR: 1.672; 95% CI: 1.002–2.791), number of sexual partners (OR: 2.092; 95% CI: 1.07–4.061), age (OR: 0.941; 95% CI: 0.734–2.791), ART start date (OR: 0.078; 95% CI: 0.042–0.141), partner HIV status (OR: 0.621; 95% CI: 0.387–0.995) and the number of hospitalizations after HIV diagnosis (OR: 0.173; 95% CI: 0.092–0.326). were significantly associated with viral load detection. Furthermore, SDI patients who defaulted treatment were 2.4 (95% CI: 1.165–4.928) times more likely to have increased viral load than those who had been returned in care. Conclusion: Viral suppression under SDI proved higher but with poor retention in care. However, the results also emphasise a vital need, to not only streamline processes to increase immediate ART uptake further, but also to ensure retention in care. [ABSTRACT FROM AUTHOR]

Background: While there have been efforts to develop frameworks to guide healthcare priority setting; there has been limited focus on evaluation frameworks. Moreover, while the few frameworks identify quality indicators for successful priority setting, they do not provide the users with strategies to verify these indicators. Kapiriri and Martin (Health Care Anal 18:129-147, 2010) developed a framework for evaluating priority setting in low and middle income countries. This framework provides BOTH parameters for successful priority setting and proposes means of their verification. Before its use in real life contexts, this paper presents results from a validation process of the framework.Methods: The framework validation involved 53 policy makers and priority setting researchers at the global, national and sub-national levels (in Uganda). They were requested to indicate the relative importance of the proposed parameters as well as the feasibility of obtaining the related information. We also pilot tested the proposed means of verification.Results: Almost all the respondents evaluated all the parameters, including the contextual factors, as 'very important'. However, some respondents at the global level thought 'presence of incentives to comply', 'reduced disagreements', 'increased public understanding,' 'improved institutional accountability' and 'meeting the ministry of health objectives', which could be a reflection of their levels of decision making. All the proposed means of verification were assessed as feasible with the exception of meeting observations which would require an insider. These findings results were consistent with those obtained from the pilot testing.Conclusions: These findings are relevant to policy makers and researchers involved in priority setting in low and middle income countries. To the best of our knowledge, this is one of the few initiatives that has involved potential users of a framework (at the global and in a Low Income Country) in its validation. The favorable validation of all the parameters at the national and sub-national levels implies that the framework has potential usefulness at those levels, as is. The parameters that were disputed at the global level necessitate further discussion when using the framework at that level. The next step is to use the validated framework in evaluating actual priority setting at the different levels. [ABSTRACT FROM AUTHOR]

Background: Adaptation of interventions is inevitable during translation to new populations or settings. Systematic approach to adaptation can ensure that fidelity to core functions of the intervention are preserved while optimizing implementation feasibility and effectiveness for the local context. In this study, we used an iterative, mixed methods, and stakeholder-engaged process to systematically adapt Collaborative Decision Skills Training for Veterans with psychosis currently participating in VA Psychosocial Rehabilitation and Recovery Centers. Methods: A modified approach to Intervention Mapping (IM-Adapt) guided the adaptation process. An Adaptation Resource Team of five Veterans, two VA clinicians, and four researchers was formed. The Adaptation Resource Team engaged in an iterative process of identifying and completing adaptations including individual qualitative interviews, group meetings, and post-meeting surveys. Qualitative interviews were analyzed using rapid matrix analysis. We used the modified, RE-AIM enriched expanded Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME) to document adaptations. Additional constructs included adaptation size and scope; implementation of planned adaptation (yes–no); rationale for non-implementation; and tailoring of adaptation for a specific population (e.g., Veterans). Results: Rapid matrix analysis of individual qualitative interviews resulted in 510 qualitative codes. Veterans and clinicians reported that the intervention was a generally good fit for VA Psychosocial Rehabilitation and Recovery Centers and for Veterans. Following group meetings to reach adaptation consensus, 158 adaptations were completed. Most commonly, adaptations added or extended a component; were small in size and scope; intended to improve the effectiveness of the intervention, and based on experience as a patient or working with patients. Few adaptations were targeted towards a specific group, including Veterans. Veteran and clinician stakeholders reported that these adaptations were important and would benefit Veterans, and that they felt heard and understood during the adaptation process. Conclusions: A stakeholder-engaged, iterative, and mixed methods approach was successful for adapting Collaborative Decision Skills Training for immediate clinical application to Veterans in a psychosocial rehabilitation center. The ongoing interactions among multiple stakeholders resulted in high quality, tailored adaptations which are likely to be generalizable to other populations or settings. We recommend the use of this stakeholder-engaged, iterative approach to guide adaptations. [ABSTRACT FROM AUTHOR]

Background: An increasing number of countries are using or planning to use quality indicators (QIs) in residential long-term care. Knowledge regarding the current state of evidence on usage and methodological soundness of publicly reported clinical indicators of quality in nursing homes is needed. The study aimed to answer the questions: 1) Which health-related QIs for residents in long-term care are currently publicly reported internationally? and 2) What is the methodological quality of these indicators?Methods: A systematic search was conducted in the electronic databases PubMed, CINAHL and Embase in October 2019 and last updated on August 31st, 2022. Grey literature was also searched. We used the Appraisal of Indicators through Research and Evaluation (AIRE) instrument for the methodological quality assessment of the identified QIs.Results: Of 23'344 identified records, 22 articles and one report describing 21 studies met the inclusion criteria. Additionally, we found 17 websites publishing information on QIs. We identified eight countries publicly reporting a total of 99 health-related QIs covering 31 themes. Each country used between six and 31 QIs. The most frequently reported indicators were pressure ulcers, falls, physical restraints, and weight loss. For most QI sets, we found basic information regarding e.g., purpose, definition of the indicators, risk-adjustment, and stakeholders' involvement in QIs' selection. Little up to date information was found regarding validity, reliability and discriminative power of the QIs. Only the Australian indicator set reached high methodological quality, defined as scores of 50% or higher in all four AIRE instrument domains.Conclusions: Little information is available to the public and researchers for the evaluation of a large number of publicly reported QIs in the residential long-term care sector. Better reporting is needed on the methodological quality of QIs in this setting, whether they are meant for internal quality improvement or provider comparison. [ABSTRACT FROM AUTHOR]

Background: Quality of care in colonoscopy is closely related to colonoscopy participants and the nursing workforce in endoscopy-related settings. However, limited data are available on the evaluations and recommendations regarding quality indicators for nursing care by these two groups. Therefore, the aim of this study was to explore the standards and requirements of quality of care in colonoscopy from the perspectives of patients and nurses.Method: With a descriptive qualitative study, semi-structured interviews were conducted between November 2021 and January 2022 with colonoscopy participants (P = 11) and nursing workforce (N = 7) in the endoscopy unit in a tertiary hospital. The interviews were analyzed using a thematic analysis.Results: Nine major themes emerged according to the structure, process, and outcome care quality model: workforce structure, quality requirements, unit facilities, nursing tools, nursing quality control systems, dynamic assessment and intervention, pre-examination care, strengthening education, and colonoscopy outcomes.Conclusion: The indicator of quality of colonoscopy care should be used to assess and improve current practices to ensure a more direct and sustained impact of colonoscopy care. This study highlights the importance of nurse managers valuing the opinions and reflections of people involved in colonoscopy to improve the quality of colonoscopy care. [ABSTRACT FROM AUTHOR]

Background: Although many quality indicator (QI) sets have been developed for acute cardiovascular diseases, a comprehensive summary is lacking. In this scoping review we aimed to summarize the available evidence on the QI sets for acute cardiovascular diseases, and assess the QI set development process. We followed the Joanna Briggs Institute framework and the PRISMA extension for scoping reviews.Methods: We conducted a systematic search of MEDLINE, EMBASE, and major international guidelines on QIs for acute major cardiovascular diseases. The study included articles published after 2000.Results: Among the 3112 articles screened, 18 were included in this scoping review. Among the 18 articles included, 12 were on acute coronary syndrome (ACS), five on acute heart failure (AHF), and two on acute aortic dissection (AAD); one article included QIs for both ACS and AHF. Only four of these studies conducted a systematic search with a search strategy. From the 18 articles, 268 QIs containing duplication between articles were identified (191 QIs were for ACS, 57 were for AHF, and 20 were for AAD) and QI measurements varied across articles.Conclusions: This scoping review provides a comprehensive list of QIs for acute cardiovascular diseases. Our results may be helpful to clinicians and organizations seeking to develop QIs for acute cardiovascular care in the future. [ABSTRACT FROM AUTHOR]

Background: Healthcare accreditation standards are advocated as an important means of improving clinical practice and organisational performance. Standard development agencies have documented methodologies to promote open, transparent, inclusive development processes where standards are developed by members. They assert that their methodologies are effective and efficient at producing standards appropriate for the health industry. However, the evidence to support these claims requires scrutiny. The study's purpose was to examine the empirical research that grounds the development methods and application of healthcare accreditation standards. Methods: A multi-method strategy was employed over the period March 2010 to August 2011. Five academic health research databases (Medline, Psych INFO, Embase, Social work abstracts, and CINAHL) were interrogated, the websites of 36 agencies associated with the study topic were investigated, and a snowball search was undertaken. Search criteria included accreditation research studies, in English, addressing standards and their impact. Searching in stage 1 initially selected 9386 abstracts. In stage 2, this selection was refined against the inclusion criteria; empirical studies (n = 2111) were identified and refined to a selection of 140 papers with the exclusion of clinical or biomedical and commentary pieces. These were independently reviewed by two researchers and reduced to 13 articles that met the study criteria. Results: The 13 articles were analysed according to four categories: overall findings; standards development; implementation issues; and impact of standards. Studies have only occurred in the acute care setting, predominately in 2003 (n = 5) and 2009 (n = 4), and in the United States (n = 8). A multidisciplinary focus (n = 9) and mixed method approach (n = 11) are common characteristics. Three interventional studies were identified, with the remaining 10 studies having research designs to investigate clinical or organisational impacts. No study directly examined standards development or other issues associated with their progression. Only one study noted implementation issues, identifying several enablers and barriers. Standards were reported to improve organisational efficiency and staff circumstances. However, the impact on clinical quality was mixed, with both improvements and a lack of measurable effects recorded. Conclusion: Standards are ubiquitous within healthcare and are generally considered to be an important means by which to improve clinical practice and organisational performance. However, there is a lack of robust empirical evidence examining the development, writing, implementation and impacts of healthcare accreditation standards. [ABSTRACT FROM AUTHOR]

Background: New approaches are often introduced to the neonatal intensive care unit (NICU) and other areas of the health service in either a haphazard or cataclysmic fashion. The needs of staff education are often addressed incompletely or too late. Rarely is education assessed after the introduction of a major change. We changed the basis of our NICU respiratory support. We conducted a major educational and support program before this intervention. This study documented and assessed the educational components of this change in our health service provision. Methods: Senior medical and nursing staff attended training abroad and an education program was applied for one year prior to the change. Multidisciplinary educational support for doctors, nurses and allied health was continued after the change. Assessment was by anonymous questionnaire, prior to change, at one and at nine months. Our hypothesis was that dissatisfaction with education would be greatest at one month. Results: Both theory education and practical education aspects of the new approach were rated as good to very good and this did not change with time. Difficulty of applying the technique was rated as ambivalent initially but decreased significantly over 9 months until it was rated easy to very easy (p < 0.001). Over all, the change was rated by staff as beneficial, both at the end of the education period and at nine months, with no decrease at one month. Conclusion: If education and training reaches all staff, with a system of mutual and continued support, even large changes in clinical practice can be achieved without the dissatisfaction with the educational process that is often otherwise seen. [ABSTRACT FROM AUTHOR]

Background: Implementation and uptake of novel and cost-effective medicines can improve patient health outcomes and healthcare efficiency. However, the uptake of new medicines into practice faces a wide range of obstacles. Earlier reviews provided insights into determinants for new medicine uptake (such as medicine, prescriber, patient, organization, and external environment factors). However, the methodological approaches used had limitations (e.g., single author, narrative review, narrow search, no quality assessment of reviewed evidence). This systematic review aims to identify barriers and facilitators affecting the uptake of new medicines into clinical practice and identify areas for future research.Method: A systematic search of literature was undertaken within seven databases: Medline, EMBASE, Web of Science, CINAHL, Cochrane Library, SCOPUS, and PsychINFO. Included in the review were qualitative, quantitative, and mixed-methods studies focused on adult participants (18 years and older) requiring or taking new medicine(s) for any condition, in the context of healthcare organizations and which identified factors affecting the uptake of new medicines. The methodological quality was assessed using QATSDD tool. A narrative synthesis of reported factors was conducted using framework analysis and a conceptual framework was utilised to group them.Results: A total of 66 studies were included. Most studies (n = 62) were quantitative and used secondary data (n = 46) from various databases, e.g., insurance databases. The identified factors had a varied impact on the uptake of the different studied new medicines. Differently from earlier reviews, patient factors (patient education, engagement with treatment, therapy preferences), cost of new medicine, reimbursement and formulary conditions, and guidelines were suggested to influence the uptake. Also, the review highlighted that health economics, wider organizational factors, and underlying behaviours of adopters were not or under explored.Conclusion: This systematic review has identified a broad range of factors affecting the uptake of new medicines within healthcare organizations, which were grouped into patient, prescriber, medicine, organizational, and external environment factors. This systematic review also identifies additional factors affecting new medicine use not reported in earlier reviews, which included patient influence and education level, cost of new medicines, formulary and reimbursement restrictions, and guidelines.Registration: PROSPERO database (CRD42018108536). [ABSTRACT FROM AUTHOR]

Background: Valid and reliable quality measures can help catalyze improvements in health care. The care of transgender patients is ripe for quality measurement, as there is increasing awareness of the increasing prevalence of this population and the urgency of improving the health care they receive. While best practices may not exist for some aspects of transgender health care, other aspects are characterized by well-developed and highly evidence-based recommendations. Our objective was to create a list of potential quality measures for transgender care.Methods and Results: In consultation with our advisory panel, which consisted of clinical and academic experts in transgender medicine, we selected eight prominent clinical practice guidelines of transgender health care for review. Our four team investigators carefully reviewed all eight clinical practice guidelines. Through the course of multiple consensus-building meetings, we iteratively refined items until we had agreed upon a list of forty potential quality measures, all of which met the criteria for quality measures set forth in the Center for Medicare and Medicaid Services Blueprint for developing quality measures.Conclusions: This manuscript explains the origin of the quality measures we developed, and also provides a useful roadmap to any group hoping to develop quality measures for a field that has not previously had any. [ABSTRACT FROM AUTHOR]

Keywords: Medical professionalism; Medical education; Medical research; Public health; Health management; Health policy EN Medical professionalism Medical education Medical research Public health Health management Health policy 1 5 5 12/09/20 20201209 NES 201209 Medicine in the twenty-first century Imagine that physicians could multiply their impact on people's health and improve community health whilst tailoring the delivery of care to each individual patient. Updating the physician's commitment and medical theory is necessary because dual clinical/public health medical practice is a scientific requirement to optimise the physician's impacts on individual and collective health. They in turn were indebted to Prof. GL Engel, the British and Ugandan doctors and medical officers working at Makerere University in the 1950s and 1960s, Dr. Halfdan Mahler, former Director of WHO, and Professor Debabar Banerji of Jawaharlal Nehru University, Delhi. With a feeling of injustice to the many colleagues that we could not cite, we should like to single out a few field practitioners in healthcare services who shared with us their energy, experience, and thoughts: Doctors and Professors Valérie Alaluf, Bernard Hanson, and Marie-Jeanne Wuidar in Belgium; Lucio Abad and Edgar Rojas in Ecuador; and Abdoulaye Sow in Guinea. [Extracted from the article]

Background: Patients' increasing needs and expectations require an overall assessment of hospital performance. Several international agencies have defined performance indicators sets but there exists no unanimous classification. The Impact HTA Horizon2020 Project wants to address this aspect, developing a toolkit of key indicators to measure hospital performance. The aim of this review is to identify and classify the dimensions of hospital performance indicators in order to develop a common language and identify a shared evidence-based way to frame and address performance assessment.Methods: Following the PRISMA statement, PubMed, Cochrane Library and Web of Science databases were queried to perform an umbrella review. Reviews focusing on hospital settings, published January 2000-June 2019 were considered. The quality of the studies selected was assessed using the AMSTAR2 tool.Results: Six reviews ranging 2002-2014 were included. The following dimensions were described in at least half of the studies: 6 studies classified efficiency (55 indicators analyzed); 5 studies classified effectiveness (13 indicators), patient centeredness (10 indicators) and safety (8 indicators); 3 studies responsive governance (2 indicators), staff orientation (10 indicators) and timeliness (4 indicators). Three reviews did not specify the indicators related to the dimensions listed, and one article gave a complete definition of the meaning of each dimension and of the related indicators.Conclusions: The research shows emphasis of the importance of patient centeredness, effectiveness, efficiency, and safety dimensions. Especially, greater attention is given to the dimensions of effectiveness and efficiency. Assessing the overall quality of clinical pathways is key in guaranteeing a truly effective and efficient system but, to date, there still exists a lack of awareness and proactivity in terms of measuring performance of nodes within networks. The effort of classifying and systematizing performance measurement techniques across hospitals is essential at the organizational, regional/national and possibly international levels to deliver top quality care to patients. [ABSTRACT FROM AUTHOR]

Background: Patient-Centered Medical Home (PCMH) adoption is an important strategy to help improve primary care quality within Health Resources and Service Administration (HRSA) community health centers (CHC), but evidence of its effect thus far remains mixed. A limitation of previous evaluations has been the inability to account for the proportion of CHC delivery sites that are designated medical homes.Methods: Retrospective cross-sectional study using HRSA Uniform Data System (UDS) and certification files from the National Committee for Quality Assurance (NCQA) and the Joint Commission (JC). Datasets were linked through geocoding and an approximate string-matching algorithm. Predicted probability scores were regressed onto 11 clinical performance measures using 10% increments in site-level designation using beta logistic regression.Results: The geocoding and approximate string-matching algorithm identified 2615 of the 6851 (41.8%) delivery sites included in the analyses as having been designated through the NCQA and/or JC. In total, 74.7% (n = 777) of the 1039 CHCs that met the inclusion criteria for the analysis managed at least one NCQA- and/or JC-designated site. A proportional increase in site-level designation showed a positive association with adherence scores for the majority of all indicators, but primarily among CHCs that designated at least 50% of its delivery sites. Once this threshold was achieved, there was a stepwise percentage point increase in adherence scores, ranging from 1.9 to 11.8% improvement, depending on the measure.Conclusion: Geocoding and approximate string-matching techniques offer a more reliable and nuanced approach for monitoring the association between site-level PCMH designation and clinical performance within HRSA's CHC delivery sites. Our findings suggest that transformation does in fact matter, but that it may not appear until half of the delivery sites become designated. There also appears to be a continued stepwise increase in adherence scores once this threshold is achieved. [ABSTRACT FROM AUTHOR]

Background: Accurate diagnosis of anemia by community workers using a point-of-care device is a challenge. The objective of the study was to establish the diagnostic accuracy of point-of-care devices for detecting anemia in community settings.Methods: It was diagnostic accuracy study with cross-sectional design on adult patients attending the outpatient department of rural/ urban health centres of Medical colleges from India. The index tests were HemoCue, TrueHb, Massimo's device and spectroscopic device, compared against autoanalyzer (gold standard). Accuracy was expressed by sensitivity, specificity, likelihood ratios, predictive values, area under the curve (AUC) and levels of agreement. For the diagnostic accuracy component, 1407 participants were recruited with a minimum of 600 for each device. An additional 200 participants were considered to elucidate the performance of devices in different weather conditions.Results: HemoCue and TrueHb performed better than Massimo and spectroscopic devices. Detection of anemia by technicians was similar between TrueHb and HemoCue (AUC 0.92 v/s 0.90, p > 0.05). Community workers performed better with Hemocue for detecting anemia compared to TrueHb (AUC 0.92 v/s 0.90, p < 0.05). For detection of severe anemia, accuracy of TrueHb was significantly better with technicians (AUC 0.91 v/s 0.70; p < 0.05) and community workers (AUC 0.91 v/s 0.73; p < 0.05). HemoCue showed a bias or mean difference (95%CI) of 0.47 g/dl (0.42, 0.52) for all values, and 0.92 g/dl (0.82, 1.03) for severe anemia. For TrueHb, it was - 0.28 g/dl (- 0.37, - 0.20) for all readings, and 0.06 g/dl (- 0.52, 0.63) for severe anemia. TrueHb appeared to be more consistent across different weather conditions, although it overestimated Hb in extreme cold weather conditions.Conclusion: For detection of anemia, True Hb and HemoCue were comparable. For severe anemia, True Hb seemed to be a better and feasible point-of-care device for detecting anemia in the community settings. [ABSTRACT FROM AUTHOR]

Background: Anaemia and malaria are both major contributors to maternal and child mortality, and morbidity, with some of the worst outcomes occurring in sub-Saharan Africa. Point of care tests (POCT), if used appropriately, provide a simple, inexpensive form of diagnostic testing, as a reliable alternative when laboratory tests are not readily available. In such resource limited settings, clinical staff tend to rely on symptom-based diagnosis and presumptive treatment. This study uses qualitative methods to identify the current practice of POCT use for malaria and anaemia, to explore the enablers and barriers to effective implementation of these POCT, and to determine how relationships between each of the stakeholder groups may impact on POCT use.Methods: Staff (clinical and laboratory) and patients (pregnant women) at three antenatal care facilities within the Ashanti Region of Ghana participated in interviews and focus group discussions (FGDs). An initial coding framework was developed based on the pre-defined objectives of the study. Thematic analysis was used to identify subthemes and categories within each of the key themes.Results: At the time data were collected all three facilities used malaria POCT either as an adjunct to microscopy, or as their only form of malaria testing. Although all three facilities were familiar with haemoglobin colour scale (HCS), none of the facilities used them routinely. Clinical staff perceived symptom-based diagnosis was a quick way to diagnosis because access to POCT during consultations was unreliable, but recognized disadvantages associated with symptom-based diagnosis. Perceived advantages of malaria and anaemia POCT were user-friendliness, improved diagnosis and opportunity for patient engagement, as well as lower cost implication for patients. Perceived disadvantages included likelihood of missed diagnosis of mild anaemia, as well as likelihood of human error leading to in accurate diagnosis which could impact on patient trust. Poor communication and lack of trust between staff groups was also identified as a barrier to effective uptake of POCT.Conclusions: Consistent supply of POCT as well as staff training and staff and patient engagement, are fundamental to successful uptake of POCT for effective malaria and anaemia management. [ABSTRACT FROM AUTHOR]

Background: In the Netherlands, health care is regulated by the Health and Youth Care Inspectorate. Forty-six indicators are used to prioritize supervision of psychiatric hospitals. The objective of this study is to define a smaller set of weighted indicators which reflects a consensus among inspectors about which aspects are most important for risk assessment.Methods: The set of 46 indicators, complemented with missing information, was reduced to six indicators by means of interviews, group discussions and ranking among the inspectors. These indicators were used as attributes in a discrete choice experiment (DCE) to define their weights.Results: Twenty-six inspectors defined the top four indicators suitable for the risk assessment of psychiatric hospitals. These are: the policy on prevention of compulsory treatment; the policy on dysfunctional professionals; the quality of internal research after a serious incident; and the implementation of multidisciplinary guidelines on suicidal behaviour. These indicators share the same importance with regard to risk assessment. The screening of somatic symptoms and the policy on integrated care are important indicators too, but less relevant.Conclusion: Through a DCE, we reduced the amount of information for risk assessment of psychiatric hospitals to six weighted indicators. Inspectors can use these indicators to prioritize their inspections. [ABSTRACT FROM AUTHOR]

Background: Dengue fever is rapidly expanding geographically, with about half of the world's population now at risk. Among the various diagnostic options, rapid diagnostic tests (RDTs) are convenient and prompt, but limited in terms of accuracy and availability.Methods: A systematic review was conducted of published data on the use of RDTs for dengue with respect to their economic impact. The search was conducted with combinations of key search terms, including "((Dengue[Title]) AND cost/economic)" and "rapid diagnostic test/assay (or point-of-care)". Articles with insufficient report on cost/economic aspect of dengue RDTs, usually on comparison of different RDTs or assessment of novel rapid diagnostic tools, were excluded. This review has been registered in the PROSPERO International prospective register of systematic reviews (registry #: CRD42015017775).Results: Eleven articles were found through advanced search on Pubmed. From Embase and Web of Science, two and 14 articles were obtained, respectively. After removal of duplicate items, title screening was done on 21 published works and 12 titles, including 2 meeting abstracts, were selected for abstract review. For full-text review, by two independent reviewers, 5 articles and 1 meeting abstract were selected. Among these, the abstract was referring to the same study results as one of the articles. After full text review, two studies (two articles and one abstract) were found to report on cost-wise or economic benefits of dengue RDTs and were selected for data extraction. One study found satisfactory performance of IgM-based Panbio RDT, concluding that it would be cost-effective in endemic settings. The second study was a modeling analysis and showed that a dengue RDT would not be advantageous in terms of cost and effectiveness compared to current practice of antibiotics prescription for acute febrile illness.Conclusions: Despite growing use of RDTs in research and clinical settings, there were limited data to demonstrate an economic impact. The available two studies reached different conclusions on the cost-effectiveness of dengue RDTs, although only one of the two studies reported outcomes from cost-effectiveness analysis of dengue and the other was considering febrile illness more generally. Evidence of such an impact would require further quantitative economic studies. [ABSTRACT FROM AUTHOR]

Background: Decentralised acute care services have, through the establishment of municipality acute wards (MAWs), been launched in Norway. The aim is to provide treatment for patients who otherwise would need hospitalisation. Currently there is a lack of studies investigating patient experiences in such services. The aims of this study were therefore to a) translate and validate the Picker Patient Experience Questionnaire (PPE-15) in Norwegian, and b) assess patient experiences in decentralised acute care, and potential factors associated with these experiences.Methods: Patients were recruited from five municipal acute wards in southeastern Norway during the period from June 2014 to June 2015. Data on socio-demographics, length of stay and comorbidity (Charlson comorbidity index (CCI)) were collected. Patients completed the Picker Patient Experience Questionnaire (PPE-15) and the EuroQOL 5-dimension, 3-level version. Convergent validity of the PPE-15 was assessed by correlation of items in PPE-15 and the Nordic Patient Experience Questionnaire (NORPEQ). A retest of the PPE-15 was performed in a subgroup of patients approximately 3 weeks after baseline assessment. Test-retest agreement was assessed with Cohens' unweighted Kappa.Results: A total of 479 patients responded, median age 78.0 years and 41.8% men. A total of 68 patients participated in the retest. Testing of convergent validity revealed an overall weak to moderate correlation. Kappa statistics showed from fair to good test-retest agreement. Most problems were related to continuity and transition, while fewest problems were related to respect for patient preferences. A higher Charlson comorbidity score was the only variable that was negatively associated with patient experience.Conclusion: Patients reported problems in several items of the PPE-15 after discharge from decentralised acute wards. The findings from the current study may be helpful for planning ways to improve quality of care, e.g., by providing feedback to healthcare personnel or by using patient experience as a quality indicator. [ABSTRACT FROM AUTHOR]

Background: The quality of pediatric emergency care has been a major concern in health care. Following a series of health system reforms in China, it is important to do this assessment of pediatric emergency care, and to explore potential influences of health care system. This study aimed to compare practice differences in treating children with respiratory illnesses in two emergency department (ED) settings within different health care systems: China and Taiwan.Methods: A pooled cross-sectional hospital-based study was conducted in two tertiary teaching hospitals in Xiamen, China and Keelung, Taiwan belong to the same hospital chain group. A team of 21 pediatricians rotated between the EDs of the two hospitals from 2009 to 2012. There were 109,705 ED encounters treated by the same team of pediatricians and 6596 visits were analyzed for common respiratory illnesses. Twelve quality measures in process and outcomes of asthma, bronchiolitis and croup were reported. Descriptive statistics and multiple logistic regression models were applied to assess. In order to demonstrate the robustness of our findings, we analyzed the data using an alternative modeling technique, multilevel modeling.Results: After adjustment, children with asthma presented to the ED in China had a significantly 76% lower likelihood to be prescribed a chest radiograph, and a 98% lower likelihood to be prescribed steroids and discharged home than those in Taiwan. Also, children with asthma presented to the ED in China had significantly 7.76 times higher risk to incur 24-72 h return visits. Furthermore, children with bronchiolitis in China (Odds ratio (OR): 0.21; 95% Confidence interval (CI): 0.17-0.28) were significantly less likely to be prescribed chest radiograph, but were significantly more likely to be prescribed antibiotics (OR: 2.19; 95% CI: 1.46-3.28).Conclusions: This study illustrated that although high quality care depends on better assessment of physician performance, the delivery of pediatric emergency care differed significantly between these two healthcare systems after holding the care providers the same and adjusting for important patient characteristics. The findings suggest that the features of the health care system may play a significant role. [ABSTRACT FROM AUTHOR]

Background: Results of associations between process and mortality indicators, both used for the external assessment of hospital care quality or public reporting, differ strongly across studies. However, most of those studies were conducted in North America or United Kingdom. Providing new evidence based on French data could fuel the international debate on quality of care indicators and help inform French policy-makers. The objective of our study was to explore whether optimal care delivery in French hospitals as assessed by their Hospital Process Indicators (HPIs) is associated with low Hospital Standardized Mortality Ratios (HSMRs).Methods: The French National Authority for Health (HAS) routinely collects for each hospital located in France, a set of mandatory HPIs. Five HPIs were selected among the process indicators collected by the HAS in 2009. They were measured using random samples of 60 to 80 medical records from inpatients admitted between January 1st, 2009 and December 31, 2009 in respect with some selection criteria. HSMRs were estimated at 30, 60 and 90 days post-admission (dpa) using administrative health data extracted from the national health insurance information system (SNIIR-AM) which covers 77% of the French population. Associations between HPIs and HSMRs were assessed by Poisson regression models corrected for measurement errors with a simulation-extrapolation (SIMEX) method.Results: Most associations studied were not statistically significant. Only two process indicators were found associated with HSMRs. Completeness and quality of anesthetic records was negatively associated with 30 dpa HSMR (0.72 [0.52-0.99]). Early detection of nutritional disorders was negatively associated with all HSMRs: 30 dpa HSMR (0.71 [0.54-0.95]), 60 dpa HSMR (0.51 [0.39-0.67]) and 90 dpa HSMR (0.52 [0.40-0.68]).Conclusion: In absence of gold standard of quality of care measurement, the limited number of associations suggested to drive in-depth improvements in order to better determine associations between process and mortality indicators. A smart utilization of both process and outcomes indicators is mandatory to capture aspects of the hospital quality of care complexity. [ABSTRACT FROM AUTHOR]

Background: Clinical quality indicators are used to monitor the performance of healthcare services and should wherever possible be based on research evidence. Little is known however about the extent to which indicators in common use are based on research. The objective of this study is to measure the extent to which clinical quality indicators used in asthma management in children with outcome measurements can be linked to results in randomised controlled clinical trial (RCT) reports. This work is part of a broader research program to trial methods that improve the efficiency and accuracy of indicator development.Methods: National-level indicators for asthma management in children were extracted from the National Quality Measures Clearinghouse database and the National Institute for Health and Care Excellence quality standards by two independent appraisers. Outcome measures were extracted from all published English language RCT reports for asthma management in children below the age of 12 published between 2005 and 2014. The two sets were then linked by manually mapping both to a common set of Unified Medical Language System (UMLS) concepts.Results: The analysis identified 39 indicators and 562 full text RCTs dealing with asthma management in children. About 95% (37/39) of the indicators could be linked to RCT outcome measures.Conclusions: It is possible to identify relevant RCT reports for the majority of indicators used to assess the quality of asthma management in childhood. The methods reported here could be automated to more generally support assessment of candidate indicators against the research evidence. [ABSTRACT FROM AUTHOR]

Background: An emergency triage, assessment and treatment plus admission care (ETAT+) intervention was implemented in Rwandan district hospitals to improve hospital care for severely ill infants and children. Many interventions are rarely implemented with perfect fidelity under real-world conditions. Thus, evaluations of the real-world experiences of implementing ETAT+ are important in terms of identifying potential barriers to successful implementation. This study explored the perspectives of Rwandan healthcare workers (HCWs) on the relevance of ETAT+ and documented potential barriers to its successful implementation.Methods: HCWs enrolled in the ETAT+ training were asked, immediately after the training, their perspective regarding (i) relevance of the ETAT+ training to Rwandan district hospitals; (ii) if attending the training would bring about change in their work; and (iii) challenges that they encountered during the training, as well as those they anticipated to hamper their ability to translate the knowledge and skills learned in the ETAT+ training into practice in order to improve care for severely ill infants and children in their hospitals. They wrote their perspectives in French, Kinyarwanda, or English and sometimes a mixture of all these languages that are official in the post-genocide Rwanda. Their notes were translated to (if not already in) English and transcribed, and transcripts were analyzed using thematic content analysis.Results: One hundred seventy-one HCWs were included in our analysis. Nearly all these HCWs stated that the training was highly relevant to the district hospitals and that it aligned with their work expectation. However, some midwives believed that the "neonatal resuscitation and feeding" components of the training were more relevant to them than other components. Many HCWs anticipated to change practice by initiating a triage system in their hospital and by using job aids including guidelines for prescription and feeding. Most of the challenges stemmed from the mode of the ETAT+ training delivery (e.g., language barriers, intense training schedule); while others were more related to uptake of guidelines in the district hospitals (e.g., staff turnover, reluctance to change, limited resources, conflicting protocols).Conclusion: This study highlights potential challenges to successful implementation of the ETAT+ clinical practice guidelines in order to improve quality of hospital care in Rwandan district hospitals. Understanding these challenges, especially from HCWs perspective, can guide efforts to improve uptake of clinical practice guidelines including ETAT+ in Rwanda. [ABSTRACT FROM AUTHOR]

Background: Spreading effective, guideline-based cardioprotective care quality improvement strategies between healthcare settings could yield great benefits, particularly in under-resourced contexts. Understanding the diverse factors facilitating or impeding such guideline implementation could improve cardiovascular care quality and outcomes for vulnerable patients.Methods: We sought to identify multi-level factors affecting uptake of cardioprotective care guidelines in community health centers (CHCs), within a successful trial of cross-setting implementation of an effective intervention. Quantitative analyses used multivariable logistic regression to examine in-person patient encounters at 10 CHCs from June 2011-May 2014. At these encounters, a point-of-care alert flagged adults with diabetes who were clinically indicated for, but not currently prescribed, cardioprotective medications. The main outcome measure was the rate of relevant prescriptions issued within two days of encounters. Qualitative analyses focused on CHC providers and staff, and, guided by the constant comparative method, were used to enhance understanding of the factors that influenced this prescribing.Results: Recommended prescribing occurred at 13-16% of encounters with patients who were indicated for such prescribing. The odds of this prescribing were higher when the patient was male, had HbA1c ≥7, was previously prescribed a similar medication, gave diabetes as the chief complaint, saw a mid-level practitioner, or saw their primary care provider. The odds were lower when the patient was insured, had ≥1 clinic visits in the past year, had kidney disease, or was prescribed certain other medications. Additional factors were associated with prescribing of each medication class. Qualitative results both supported and challenged the quantitative findings, illustrating important tensions involved in guideline-based prescribing. Clinic staff stressed the importance of the provider-patient relationship in guiding prescribing decisions in the face of competing priorities and care needs, and the impact of rapidly changing guidelines.Conclusions: Diverse factors associated with guideline-concordant prescribing illuminate the complexity of delivering evidence-based care in CHCs. We present possible strategies for addressing barriers to guideline-based prescribing.Clinical Trials Registration: This trial was registered retrospectively. Currently Controlled Trials NCT02299791 . Retrospectively registered 10 November 2014. [ABSTRACT FROM AUTHOR]

Background: Demographic changes are leading to an ageing population in Europe, and predict an increase in the number of nursing home residents over the next 30 years. Nursing home residents need specialised healthcare services such as radiology due to both chronic and acute illnesses. Mobile radiography, x-ray examinations performed in the nursing homes, may be a good way of providing services to this population. The aim of this systematic review was to identify the outcomes of mobile radiography services for nursing home residents and society.Methods: A systematic review based on searches in the Medline, Cochrane, PubMed, Embase and Svemed + databases was performed. Titles and abstracts were screened according to a predefined set of inclusion criteria: empirical studies in the geriatric population, and reports of mobile radiography services in a clinical setting. All publications were quality appraised using MMAT or CASP appraisal tools. Data were extracted using a summary table and results were narratively synthesised.Results: Ten publications were included. Three overarching outcomes were identified: 1) reduced number of hospitalisations and outpatient examinations or treatments, 2) reduced number of transfers between nursing homes and hospitals and 3) increased access to x-ray examinations. These outcomes were interlinked with the more specific outcomes for residents and society reported in the literature. For residents there was a reduction in burdensome transfers and waiting time and adequate treatment and care increased. For society, released resources could be used more efficiently, and overall costs were reduced substantially.Conclusions: This review indicates that mobile radiography services for nursing home residents in the western world are of comparable quality to hospital-based examinations and have clear potential benefits. Mobile radiography reduced transfers to and from hospital, increased the number of examinations carried out and facilitated timely diagnosis and access to treatments. Further research is needed to formally evaluate potential improvements in care quality and cost-effectiveness. [ABSTRACT FROM AUTHOR]

Background: Results-based financing (RBF) has been introduced in many countries across Africa and a growing literature is building around the assessment of their impact. These studies are usually quantitative and often silent on the paths and processes through which results are achieved and on the wider health system effects of RBF. To address this gap, our study aims at exploring the implementation of an RBF pilot in Benin, focusing on the verification of results.Methods: The study is based on action research carried out by authors involved in the pilot as part of the agency supporting the RBF implementation in Benin. While our participant observation and operational collaboration with project's stakeholders informed the study, the analysis is mostly based on quantitative and qualitative secondary data, collected throughout the project's implementation and documentation processes. Data include project documents, reports and budgets, RBF data on service outputs and on the outcome of the verification, daily activity timesheets of the technical assistants in the districts, as well as focus groups with Community-based Organizations and informal interviews with technical assistants and district medical officers.Results: Our analysis focuses on the actual practices of quantitative, qualitative and community verification. Results show that the verification processes are complex, costly and time-consuming, and in practice they end up differing from what designed originally. We explore the consequences of this on the operation of the scheme, on its potential to generate the envisaged change. We find, for example, that the time taken up by verification procedures limits the time available for data analysis and feedback to facility staff, thus limiting the potential to improve service delivery. Verification challenges also result in delays in bonus payment, which delink effort and reward. Additionally, the limited integration of the verification activities of district teams with their routine tasks causes a further verticalization of the health system.Conclusions: Our results highlight the potential disconnect between the theory of change behind RBF and the actual scheme's implementation. The implications are relevant at methodological level, stressing the importance of analyzing implementation processes to fully understand results, as well as at operational level, pointing to the need to carefully adapt the design of RBF schemes (including verification and other key functions) to the context and to allow room to iteratively modify it during implementation. They also question whether the rationale for thorough and costly verification is justified, or rather adaptations are possible. [ABSTRACT FROM AUTHOR]

Background: Hospital readmissions are associated with higher resource utilization and worse patient outcomes. Causes of unplanned readmission to the hospital are multiple with some being better targets for intervention than others. To understand risk factors for surgical readmission and their incremental contribution to current Veterans Health Administration (VA) surgical quality assessment, the study, Improving Surgical Quality: Readmission (ISQ-R), is being conducted to develop a readmission risk prediction tool, explore predisposing and enabling factors, and identify and rank reasons for readmission in terms of salience and mutability.Methods: Harnessing the rich VA enterprise data, predictive readmission models are being developed in data from patients who underwent surgical procedures within the VA 2007-2012. Prospective assessment of psychosocial determinants of readmission including patient self-efficacy, cognitive, affective and caregiver status are being obtained from a cohort having colorectal, thoracic or vascular procedures at four VA hospitals in 2015-2017. Using these two data sources, ISQ-R will develop readmission categories and validate the readmission risk prediction model. A modified Delphi process will convene surgeons, non-surgeon clinicians and quality improvement nurses to rank proposed readmission categories vis-à-vis potential preventability.Discussion: ISQ-R will identify promising avenues for interventions to facilitate improvements in surgical quality, informing specifications for surgical workflow managers seeking to improve care and reduce cost. ISQ-R will work with Veterans Affairs Surgical Quality Improvement Program (VASQIP) to recommend potential new elements VASQIP might collect to monitor surgical complications and readmissions which might be preventable and ultimately improve surgical care. [ABSTRACT FROM AUTHOR]

Background: In an era of a rapidly aging population who requires home care services, clients must possess or develop therapeutic self-care ability in order to manage their health conditions safely in their homes. Therapeutic self-care is the ability to take medications as prescribed and to recognize and manage symptoms that may be experienced, such as pain. The purpose of this research study was to investigate whether therapeutic self-care ability explained variation in the frequency and types of adverse events experienced by home care clients.Methods: A retrospective cohort design was used, utilizing secondary databases available for Ontario home care clients from the years 2010 to 2012. The data were derived from (1) Health Outcomes for Better Information and Care; (2) Resident Assessment Instrument-Home Care; (3) National Ambulatory Care Reporting System; and (4) Discharge Abstract Database. Descriptive analysis was used to identify the types and prevalence of adverse events experienced by home care clients. Logistic regression analysis was used to examine the association between therapeutic self-care ability and the occurrence of adverse events in home care.Results: The results indicated that low therapeutic self-care ability was associated with an increase in adverse events. In particular, logistic regression results indicated that low therapeutic self-care ability was associated with an increase in clients experiencing: (1) unplanned hospital visits; (2) a decline in activities of daily living; (3) falls; (4) unintended weight loss, and (5) non-compliance with medication.Conclusions: This study advances the understanding about the role of therapeutic self-care ability in supporting the safety of home care clients. High levels of therapeutic self-care ability can be a protective factor against the occurrence of adverse events among home care clients. A clear understanding of the nature of the relationship between therapeutic self-care ability and adverse events helps to pinpoint the areas of home care service delivery required to improve clients' health and functioning. Such knowledge is vital for informing health care leaders about effective strategies that promote therapeutic self-care, as well as providing evidence for policy formulation in relation to risk mitigation in home care. [ABSTRACT FROM AUTHOR]

Background: The Papua New Guinea Department of Health recently shifted from a presumptive to a 'test and treat' malaria case management policy. This shift was supported by the widespread introduction of malaria rapid diagnostic tests in health facilities across the country. Health workers received training and job-aids detailing how to conduct and interpret a malaria rapid diagnostic test and how to treat test positive cases; however, little instruction on treating non-malaria febrile cases was provided. Accordingly, this study examined health worker case management of non-malarial febrile patients in the 12-month period immediately following the introduction of the revised malaria case management policy.Methods: Data were collected from a country-wide cross-sectional survey of febrile case management at randomly selected health facilities and from longitudinal surveillance at sentinel health facilities. Analysis was restricted to febrile patients who tested negative for malaria infection by rapid diagnostic test (N=303 and 5705 outpatients, respectively).Results and Discussion: 96.8% of non-malarial febrile patients received a diagnosis in the longitudinal sample, compared to 52.4% of the cross-sectional sample. Respiratory tract infections were the most commonly reported diagnoses. Over 90% of patients in both samples were prescribed one or more medications, most commonly an analgesic (71.3 & 72.9% of the longitudinal and cross-sectional samples, respectively), some form of antibiotic (72.7 & 73.4%, respectively) and/or an anthelminthic (17.9 & 16.5%, respectively). Prescribing behaviour was adherent with the recommendations in the standard treatment guidelines in fewer than 20% of cases (longitudinal sample only).Conclusion: Many non-malarial febrile patients are not provided with a diagnosis. When diagnoses are provided they are typically some form of respiratory tract infection. Antibiotics and analgesics are widely prescribed, although medications prescribed rarely adhere to the Papua New Guinea standard treatment guidelines. These findings indicate that Papua New Guinea health workers require support for non-malarial febrile illness case management. [ABSTRACT FROM AUTHOR]

Background: Communication between involved parties is essential to ensure coordinated and safe health care delivery. However, existing literature reveals that the information relayed in the referral process is seen as insufficient by the receivers. It is unknown how this insufficiency affects the quality of care, and valid performance measures to explore it are lacking. The aim of the present study was to develop quality indicators to detect the impact that the quality of referral letters from primary care to specialised mental health care has on the quality of mental health services.Methods: Using a modified version of the RAND/UCLA appropriateness method, a systematic literature review and focus group interviews were conducted to define quality indicators for mental health care expected to be affected by the quality of referral information. Focus group participants included psychiatrists, psychologists, general practitioners, patient representatives and managers. The existing evidence and suggested indicators were presented to expert panels, who assessed the indicators by their validity, reliability, sensitivity and feasibility.Results: Sixteen preliminary indicators emerged during the focus group interviews and literature review. The expert panels recommended four of the 16 indicators. The recommended indicators measure a) timely access, b) delay in the process of assessing the referral, c) delay in the onset of care and d) the appropriateness of the referral. Adjustment was necessary for five other indicators, and seven indicators were rejected because of expected confounding factors reducing their validity and sensitivity.Conclusions: The quality of information relayed in the referral process from primary care to specialised mental health care is expected to affect a wide range of dimensions defining high quality care. The expected importance of the referral process for ensuring 'timely access'-one of the six aims of high-quality health care defined by the Institute of Medicine-is highlighted. Exploring the underlying mechanisms for the potential impact of referral information on patient outcomes is recommended to enhance quality of care.Trial Registration: ClinicalTrials.gov: NCT01374035 (28 April 2011). [ABSTRACT FROM AUTHOR]

Background: The needs of the growing population of complex patients with multiple chronic conditions calls for a different approach to care. Clinical teams need to acknowledge, respect, and support the work that patients do and the capacity they mobilize to enact this work, and to adapt and self-manage. Tools that enable this approach to care are needed. Methods: Using user-centered design principles, we set out to create a discussion aid for use by patients, clinicians, and other health professionals during clinical encounters. We observed clinical encounters, visited patient homes, and dialogued with patient support groups. We then developed and tested prototypes in routine clinical practice. Then we refined a final prototype with extensive stakeholder feedback. Results: From this process resulted the ICAN Discussion Aid, a tool completed by the patient and reviewed during the consultation in which patients classified domains that contribute to capacity as sources of burden or satisfaction; clinical demands were also classified as sources of help or burden. The clinical review facilitated by ICAN generates hypotheses regarding why some treatment plans may be problematic and may not be enacted in the patient's situation. Conclusion: We successfully created a discussion aid to elucidate and share insights about the capacity patients have to enact the treatment plan and hypotheses as to why this plan may or may not be enacted. Next steps involve the evaluation of the impact of the ICAN Discussion Aid on clinical encounters with a variety of health professionals and the impact of ICAN-informed treatment plans on patient-important outcomes. [ABSTRACT FROM AUTHOR]

Background: The use of interorganizational, collaborative approaches to build capacity in quality improvement (QI) in health care is showing promise as a useful model for scaling up and accelerating the implementation of interventions that bridge the "know-do" gap to improve clinical care and provider outcomes. Fundamental to a collaborative approach is interorganizational learning whereby organizations acquire, share, and combine knowledge with other organizations and have the opportunity to learn from their respective successes and challenges in improvement areas. This learning approach aims to create the conditions for collaborative, reflective, and innovative experiential systems that enable collective discussions regarding daily practice issues and finding solutions for improvement.Methods: The concepts associated with interorganizational learning and deliberate learning activities within a collaborative 'Communities-of-practice'(CoP) approach formed the foundation of the of an interactive QI knowledge translation initiative entitled PERFORM KT. Nine teams participated including seven teams from two acute care hospitals, one from a long term care center, and one from a mental health sciences center. Six monthly CoP learning sessions were held and teams, with the support of an assigned mentor, implemented a QI project and monitored their results which were presented at an end of project symposium. 47 individuals participated in either a focus group or a personal interview. Interviews were transcribed and analyzed using an iterative content analysis.Results: Four key themes emerged from the narrative dataset around experiences and perceptions associated with the PERFORM KT initiative: 1) being successful and taking it to other levels by being systematic, structured, and mentored; 2) taking it outside the comfort zone by being exposed to new concepts and learning together; 3) hearing feedback, exchanging stories, and getting new ideas; and 4) having a pragmatic and accommodating approach to apply new learnings in local contexts.Conclusions: Study findings offer insights into collaborative, inter-organizational CoP learning approaches to build QI capabilities amongst clinicians, staff, and managers. In particular, our study delineates the need to contextualize QI learning by using deliberate learning activities to balance systematic and structured approaches alongside pragmatic and accommodating approaches with expert mentors. [ABSTRACT FROM AUTHOR]

Background: Reducing low-value care is a core component of healthcare reforms in many Western countries. A comprehensive and sound set of low-value care measures is needed in order to monitor low-value care use in general and in provider-payer contracts. Our objective was to review the scientific literature on low-value care measurement, aiming to assess the scope and quality of current measures.Methods: A systematic review was performed for the period 2010-2015. We assessed the scope of low-value care recommendations and measures by categorizing them according to the Classification of Health Care Functions. Additionally, we assessed the quality of the measures by 1) analysing their development process and the level of evidence underlying the measures, and 2) analysing the evidence regarding the validity of a selected subset of the measures.Results: Our search yielded 292 potentially relevant articles. After screening, we selected 23 articles eligible for review. We obtained 115 low-value care measures, of which 87 were concentrated in the cure sector, 25 in prevention and 3 in long-term care. No measures were found in rehabilitative care and health promotion. We found 62 measures from articles that translated low-value care recommendations into measures, while 53 measures were previously developed by institutions as the National Quality Forum. Three measures were assigned the highest level of evidence, as they were underpinned by both guidelines and literature evidence. Our search yielded no information on coding/criterion validity and construct validity for the included measures. Despite this, most measures were already used in practice.Conclusion: This systematic review provides insight into the current state of low-value care measures. It shows that more attention is needed for the evidential underpinning and quality of these measures. Clear information about the level of evidence and validity helps to identify measures that truly represent low-value care and are sufficiently qualified to fulfil their aims through quality monitoring and in innovative payer-provider contracts. This will contribute to creating and maintaining the support of providers, payers, policy makers and citizens, who are all aiming to improve value in health care. [ABSTRACT FROM AUTHOR]

Background: Use of Shared Decision-Making (SDM) and Decision Aids (DAs) has been encouraged but is not regularly implemented in primary care. The Office-Guidelines Applied to Practice (Office-GAP) intervention is an application of a previous model revised to address guidelines based care for low-income populations with diabetes and coronary heart disease (CHD).Objective: To evaluate Office-GAP Program feasibility and preliminary efficacy on medication use, patient satisfaction with physician communication and confidence in decision in low-income population with diabetes and coronary heart disease (CHD) in a Federally Qualified Healthcare Center (FQHC).Method: Ninety-five patients participated in an Office-GAP program. A quasi-experimental design study, over 6 months with 12-month follow-up. Office-GAP program integrates health literacy, communication skills education for patients and physicians, patient/physician decision support tools and SDM into routine care.Main Measures: 1) Implementation rates of planned program elements 2) Patient satisfaction with communication and confidence in decision, and 3) Medication prescription rates. We used the GEE method for hierarchical logistic models, controlling for confounding.Results: Feasibility of the Office-GAP program in the FQHC setting was established. We found significant increase in use of Aspirin/Plavix, statin and beta-blocker during follow-up compared to baseline: Aspirin OR 1.5 (95 % CI: 1.1, 2.2) at 3-months, 1.9 (1.3, 2.9) at 6-months, and 1.8 (1.2, 2.8) at 12-months. Statin OR 1.1 (1.0, 1.3) at 3-months and 1.5 (1.1, 2.2) at 12-months; beta-blocker 1.8 (1.1, 2.9) at 6-months and 12-months. Program elements were consistently used (≥ 98 % clinic attendance at training and tool used). Patient satisfaction with communication and confidence in decision increased.Conclusions: The use of Office-GAP program to teach SDM and use of DAs in real time was demonstrated to be feasible in FQHCs. It has the potential to improve satisfaction with physician communication and confidence in decisions and to improve medication use. The Office-GAP program is a brief, efficient platform for delivering patient and provider education in SDM and could serve as a model for implementing guideline based care for all chronic diseases in outpatient clinical settings. Further evaluation is needed to establish feasibility outside clinical study, reach, effectiveness and cost-effectiveness of this approach. [ABSTRACT FROM AUTHOR]

Background: Rwanda has achieved great improvements in several key health indicators, including maternal mortality and other health outcomes. This raises the question: what has made this possible, and what makes Rwanda so unique?Methods: We describe the results of a web-based survey among district health managers in Rwanda who gave their personal opinions on the factors that drive performance in the health sector, in particular those that determine maternal health service coverage and outcomes. The questionnaire covered the six health systems building blocks that make up the WHO framework for health systems analysis, and two additional clusters of factors that are not directly covered by the framework: community health and determinants beyond the health sector.Results: Community health workers and health insurance come out as factors that are considered to have contributed most to Rwanda's remarkable achievements in the past decade. The results also indicate the importance of other health system features, such as managerial skills and the culture of continuous monitoring of key indicators. In addition, there are factors beyond the health sector per se, such as the widespread determination of people to increase performance and achieve targets. This determination appears multi-levelled and influenced by both intrinsic and extrinsic motivation.Conclusion: It is the comprehensiveness and combination of interventions that drive performance in Rwanda, rather than a single health systems strengthening intervention or a set of interventions that target a specific disease. There is need for policy makers and scholars to acknowledge the complexity of health systems, and the fact that they are dynamic and influenced by society's fabric, including the overall culture of performance management in the public sector. Rwanda's robust model is difficult to replicate and fast-tracking elsewhere in the world of some of the interventions that form part of its success will require a holistic approach. [ABSTRACT FROM AUTHOR]