Discussant: Prioritizing Evidence Syntheses

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Santé & Médecine Technologie

Prioritizing Evidence Syntheses Sharon E. Straus MD MSc FRCPC Canada Research Chair Knowledge Translation and Quality of Care

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Research Objective: The SAFTINet project was funded by the AHRQ to build a distributed network of existing clinical and claims data that would support comparative effectiveness research (CER), with a focus on underserved populations and healthcare delivery system (HDS) characteristics. Observational research methods are appropriate, but require detailed protocols with a priori hypotheses and analytic plans. SAFTINet research specifically concerns the effects of a discrete set of HDS features (those often included in Patient-Centered Medical Home (PCMH) models) on health outcomes for primary care patients with asthma, hypertension, and hypercholesterolemia. Our objective is to present a description of this study’s measurement challenges, and to specify a priori hypotheses, analytic strategies, and plans for addressing bias and confounding for our asthma cohorts. Study Design: An observational, longitudinal cohort study of primary care patients with asthma, with both secondary use of existing clinical and claims data and primary data collection for HDS features and patient- reported outcomes. Population Studied: Our sample consists of 59 primary care practices in 5 healthcare organizations in Colorado, Utah and Tennessee; all practices serve underserved populations. These practices care for about 275,000 patients per year, of whom an estimated 22,000 have a diagnosis of asthma. Principal Findings: We will present the processes used to define and measure the HDS features, covariates and asthma outcomes, along with planned analysis. Challenges include valid measurement of a multi-faceted HDS “exposure” variable, the inability to identify exposure onset, and the non-dichotomous nature of HDS characteristics. To measure HDS characteristics, we created a practice-level survey assessing 9 PCMH domains, including care coordination, specialty care and mental health integration, and patient-centeredness, as well as asthma-specific HDS characteristics (e.g., the use of asthma registries). Asthma outcomes included (1) those available as a result of routine electronic documentation of clinical care and claims administration (utilization indicative of an exacerbation), and (2) patient reported outcomes tools (Asthma Control Test). We used directed acyclic graphs to identify potential confounders of the relationship between HDS characteristics and asthma control, as well as other potential biases. The analytic plan is based on linear mixed effects models. Perspectives of the CER team, the technology team and the community engagement group were considered in the operationalization of all variables. Conclusions: The design of rigorous observational CER observational CER should recognize the need for an intense planning phase. In accordance with good practice guidance for observational studies, an important component of the planning phase is to disseminate and obtain feedback on the research design in advance of its conduct.

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PREPARATION Consider the hospital-acquired conditions that are not reimbursed for under Medicare/Medicaid. Among these conditions are specific safety issues such as infections, falls, medication errors, and other safety concerns that could have been prevented or alleviated with the use of evidence-based guidelines. Hospital Safety Score, an independent nonprofit organization, uses national performance measures to determine the safety score for hospitals in the United States. The Hospital Safety Score Web site and other online resources provide hospital safety scores to the public. Read the scenario below: Scenario As the manager of a unit, you have been advised by the patient safety office of an alarming increase in the hospital safety score for your unit. This is a very serious public relations matter because patient safety data is public information. It is also a financial crisis because the organization stands to lose a significant amount of reimbursement money from Medicare and Medicaid unless the source of the problem can be identified and corrected. You are required to submit a safety score improvement plan to the organization's leadership and the patient safety office. Select a specific patient safety goal that has been identified by an organization, or one that is widely regarded in the nursing profession as relevant to quality patient care delivery, such as patient falls, infection rates, catheter-induced urinary infections, IV infections, et cetera. DELIVERABLE: SAFETY SCORE IMPROVEMENT PLAN Develop a 3–5 page safety score improvement plan. Identify the health care setting and nursing unit of your choice in the title of the mitigation plan. For example, "Safety Score Improvement Plan for XYZ Rehabilitation Center." You may choose to use information on a patient safety issue for the organization in which you currently work, or search for information from a setting you are familiar with, perhaps from your clinical work. Demonstrate systems theory and systems thinking as you develop your recommendations. Organize your report with these headings: Study of Factors Identify a patient safety issue. Describe the influence of nursing leadership in driving the needed changes. Apply systems thinking to explain how current policies and procedures may affect a safety issue. Recommendations Recommend an evidence-based strategy to improve the safety issue. Explain a strategy to collect information about the safety concern. How would you determine the sources of the problem? Explain a plan to implement a recommendation and monitor outcomes. What quality indicators will you use? How will you monitor outcomes? Will policies or procedures need to be changed? Will nursing staff need training? What tools will you need to do this? Additional Requirements Written communication: Written communication should be free of errors that detract from the overall message. APA formatting: Resources and in-te ...

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Assignment Overview: One of the leading continuous quality indicators that U.S. health care managers struggle with is population-wide health equity monitoring and improvement. This indicator seems to unfortunately remain isolated from the “mainstream” process of continuous quality improvement. Because of this, health care managers remain relatively uninformed about the health equity impacts of organizational decisions, despite the ease of data gathering and assessment brought about by the advent of electronic health records. Please read the following article, then answer the Case Assignment questions. Cookson, R., Asaria, M., & Ali, S. (2018). Health equity monitoring for health care quality assurance. Social Science & Medicine, Vol. 198, 148-156. Retrieved from the Trident Online Library. (Conduct additional research to gather sufficient information to support your analysis) 1. How can the monitoring process suggested in the article help in revising the processes used inside the United States? It’s working in England—so could it work in the United States? Why or why not? Justify your answer using credible, peer-reviewed sources. 2. What are five of the current inequities in the United States health care market that should be addressed? Document each inequity using credible, peer-reviewed sources. 3. How can each of these inequities be best resolved to the satisfaction of all stakeholders? Explain your ideas for resolving the five inequities to your stakeholders in a few concise paragraphs. 3-5 PAGES. Readings : Hallam, C.R.A., & Contreras, C. (2018). Lean healthcare: Scale, scope and sustainability. International Journal of Health Care Quality Assurance, 31 (7), 684-696. Retrieved from the Trident Online Library. Harnett, P. J. (2018). Improvement attributes in healthcare: Implications for integrated care. International Journal of Health Care Quality Assurance, 31 (3), 214-227. Retrieved from the Trident Online Library. Hayhurst, C. (2018). The quest for quality: Navigating the changing landscape of healthcare technology regulations. Biomedical Instrumentation & Technology, 52 (3), 182-191. Retrieved from the Trident Online Library. Henker, H., Fox-Lewis, S., Tep, N., Vanna, D., Pol, S., & Turner, C. (2018). Healthcare workers' perceptions of an organizational quality assurance program implemented in aresource-limited setting: A qualitative study. Health Promotion Perspectives, 8 (3), 179-186. Retrieved from the Trident Online Library. Manzanera, R., Moya, D., Guilabert, M., Plana, M., Gálvez, G., Ortner, J., & Mira, J.J. (2018). Quality assurance and patient safety measures: A comparative longitudinal analysis. International Journal of Environmental Research and Public Health, 15 (8), 1568-70 Retrieved from the Trident Online Library. Stan, L. (2018). Quality management in healthcare: Performance improvement. Manager, (27), 85-92. Retrieved from the Trident Online Library. Vockley, M. (2017). Safety inn.

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Assignment Description A reputable hospital has high quality ratings from patient satisfaction surveys but is still losing market share. For many years, health care organizations, as well as traditional businesses, have been frustrated that high customer satisfaction scores do not necessarily lead to higher levels of profitability or sales. Prepare a report examining this phenomenon that address the following elements: Evaluate and explain inconsistency between customer satisfaction scores and profitability and why it tends to exist in health care organizations. Apply the statistical procedures discussed in class to support (or refute) the inconsistency. Assess price vs. quality of services as well as the impact of insurance or managed care contracts on a hospital's market share, regardless of patient satisfaction levels. Explain how you could use high patient satisfaction results to your advantage when negotiating a new managed care contract for the hospital. Discuss ethical issues involved when presenting results. Discuss how qualitative and quantitative data can be used to help this hospital improve market share. The body of the resultant report should be 5–7 pages and include at least 5 relevant peer-reviewed academic or professional references published within the past 5 years. Library Resources: Statistical Analysis 1 Below is a list of articles and summary descriptions on effective communication in health care. Click here to use the online library to search for the complete articles. Article 1 The increased use of meta-analysis in systematic reviews of health care interventions has highlighted several types of bias that can arise during the completion of a randomized controlled trial. Study publication bias and outcome reporting bias have been recognized as potential threats to the validity of meta-analysis and can make the readily available evidence unreliable for decision making. This update reviews and summarizes the evidence from cohort studies that have assessed study publication bias or outcome reporting bias in randomized controlled trials. Twenty studies were eligible, of which four were newly identified in this update. Only two followed the cohort all the way through from protocol approval to information regarding the publication of outcomes. Fifteen of the studies investigated study publication bias and five investigated outcome reporting bias. Three studies have found that statistically significant outcomes had higher odds of being fully reported as compared to nonsignificant outcomes (range of odds ratios: 2.2–4.7). In comparing trial publications to protocols, it was found that 40–62% of studies had at least one primary outcome that was changed, introduced, or omitted. It was decided not to undertake meta-analysis because of the differences between studies. This update does not change the conclusions of the review in which 16 studies were included. Direct empirical evidence for the existence of study publica ...

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