The Influence of Primary Care Quality on Hospital Admissions for People with Dementia in England: A Regression Analysis

Objectives

To test the impact of a UK pay-for-performance indicator, the Quality and Outcomes Framework (QOF) dementia review, on three types of hospital admission for people with dementia: emergency admissions where dementia was the primary diagnosis; emergency admissions for ambulatory care sensitive conditions (ACSCs); and elective admissions for cataract, hip replacement, hernia, prostate disease, or hearing loss.

Methods

Count data regression analyses of hospital admissions from 8,304 English general practices from 2006/7 to 2010/11. We identified relevant admissions from national Hospital Episode Statistics and aggregated them to practice level. We merged these with practice-level data on the QOF dementia review. In the base case, the exposure measure was the reported QOF register. As dementia is commonly under-diagnosed, we tested a predicted practice register based on consensus estimates. We adjusted for practice characteristics including measures of deprivation and uptake of a social benefit to purchase care services (Attendance Allowance).

Results

In the base case analysis, higher QOF achievement had no significant effect on any type of hospital admission. However, when the predicted register was used to account for under-diagnosis, a one-percentage point improvement in QOF achievement was associated with a small reduction in emergency admissions for both dementia (-0.1%; P=0.011) and ACSCs (-0.1%; P=0.001). In areas of greater deprivation, uptake of Attendance Allowance was consistently associated with significantly lower emergency admissions. In all analyses, practices with a higher proportion of nursing home patients had significantly lower admission rates for elective and emergency care.

Conclusion

In one of three analyses at practice level, the QOF review for dementia was associated with a small but significant reduction in unplanned hospital admissions. Given the rising prevalence of dementia, increasing pressures on acute hospital beds and poor outcomes associated with hospital stays for this patient group, this small change may be clinically and economically relevant.     

Quality Indicators for Safe Medication Preparation and Administration: A Systematic Review

Background

One-third of all medication errors causing harm to hospitalized patients occur in the medication preparation and administration phase, which is predominantly a nursing activity. To monitor, evaluate and improve the quality and safety of this process, evidence-based quality indicators can be used.

Objectives

The aim of study was to identify evidence-based quality indicators (structure, process and outcome) for safe in-hospital medication preparation and administration.

Methods

MEDLINE, EMBASE and CINAHL were searched for relevant studies published up to January 2015. Additionally, nine databases were searched to identify relevant grey literature. Two reviewers independently selected studies if (1) the method for quality indicator development combined a literature search with expert panel opinion, (2) the study contained quality indicators on medication safety, and (3) any of the quality indicators were applicable to hospital medication preparation and administration. A multidisciplinary team appraised the studies independently using the AIRE instrument, which contains four domains and 20 items. Quality indicators applicable to in-hospital medication preparation and administration were extracted using a structured form.

Results

The search identified 1683 studies, of which 64 were reviewed in detail and five met the inclusion criteria. Overall, according to the AIRE domains, all studies were clear on purpose; most of them applied stakeholder involvement and used evidence reasonably; usage of the indicator in practice was scarcely described. A total of 21 quality indicators were identified: 5 structure indicators (e.g. safety management and high alert medication), 11 process indicators (e.g. verification and protocols) and 5 outcome indicators (e.g. harm and death). These quality indicators partially cover the 7 rights.

Conclusion

Despite the relatively small number of included studies, the identified quality indicators can serve as an excellent starting point for further development of nursing specific quality indicators for medication safety. Especially on the right patient, right route, right time and right documentation there is room future development of quality indicators.     

Child-Report Measures of Occupational Performance: A Systematic Review

Introduction

Improving occupational performance is a key service of occupational therapists and client-centred approach to care is central to clinical practice. As such it is important to comprehensively evaluate the quality of psychometric properties reported across measures of occupational performance; in order to guide assessment and treatment planning.

Objective

To systematically review the literature on the psychometric properties of child-report measures of occupational performance for children ages 2–18 years.

Methods

A systematic search of the following six electronic databases was conducted: CINAHL; PsycINFO; EMBASE; PubMed; the Health and Psychosocial Instruments (HAPI) database; and Google Scholar. The quality of the studies was evaluated against the COSMIN taxonomy of measurement properties and the overall quality of psychometric properties was evaluated using pre-set psychometric criteria.

Results

Fifteen articles and one manual were reviewed to assess the psychometric properties of the six measures–the PEGS, MMD, CAPE, PAC, COSA, and OSA- which met the inclusion criteria. Most of the measures had conducted good quality studies to evaluate the psychometric properties of measures (PEGS, CAPE, PAC, OSA); however, the quality of the studies for two of these measures was relatively weak (MMD, COSA). When integrating the quality of the psychometric properties of the measures with the quality of the studies, the PAC stood out as having superior psychometric qualities.

Conclusions

The overall quality of the psychometric properties of most measures was limited. There is a need for continuing research into the psychometric properties of child-report measures of occupational performance, and to revise and improve the psychometric properties of existing measures.     

Cost-Effectiveness of Collaborative Care for the Treatment of Depressive Disorders in Primary Care: A Systematic Review

BackgroundFor the treatment of depressive disorders, the framework of collaborative care has been recommended, which showed improved outcomes in the primary care sector. Yet, an earlier literature review did not find sufficient evidence to draw robust conclusions on the cost-effectiveness of collaborative care.PurposeTo systematically review studies on the cost-effectiveness of collaborative care, compared with usual care for the treatment of patients with depressive disorders in primary care.MethodsA systematic literature search in major databases was conducted. Risk of bias was assessed using the Cochrane Collaboration’s tool. Methodological quality of the articles was assessed using the Consensus on Health Economic Criteria (CHEC) list. To ensure comparability across studies, cost data were inflated to the year 2012 using country-specific gross domestic product inflation rates, and were adjusted to international dollars using purchasing power parities (PPP).ResultsIn total, 19 cost-effectiveness analyses were reviewed. The included studies had sample sizes between n = 65 to n = 1,801, and time horizons between six to 24 months. Between 42% and 89% of the CHEC quality criteria were fulfilled, and in only one study no risk of bias was identified. A societal perspective was used by five studies. Incremental costs per depression-free day ranged from dominance to US$PPP 64.89, and incremental costs per QALY from dominance to US$PPP 874,562.ConclusionDespite our review improved the comparability of study results, cost-effectiveness of collaborative care compared with usual care for the treatment of patients with depressive disorders in primary care is ambiguous depending on willingness to pay. A still considerable uncertainty, due to inconsistent methodological quality and results among included studies, suggests further cost-effectiveness analyses using QALYs as effect measures and a time horizon of at least 1 year.     

Lowering Cardiovascular Disease Risk for People with Severe Mental Illnesses in Primary Care: A Focus Group Study

Background

People with severe mental illnesses die early from cardiovascular disease. Evidence is lacking regarding effective primary care based interventions to tackle this problem.

Aim

To identify current procedures for, barriers to, and facilitators of the delivery of primary care based interventions for lowering cardiovascular risk for people with severe mental illnesses.

Method

75 GPs, practice nurses, service users, community mental health staff and carers in UK GP practice or community mental health settings were interviewed in 14 focus groups which were audio-recorded, transcribed and analysed using Framework Analysis.

Results

Five barriers to delivering primary care based interventions for lowering cardiovascular risk in people with severe mental illnesses were identified by the groups: negative perceptions of people with severe mental illnesses amongst some health professionals, difficulties accessing GP and community-based services, difficulties in managing a healthy lifestyle, not attending appointments, and a lack of awareness of increased cardiovascular risk in people with severe mental illnesses by some health professionals. Identified facilitators included involving supportive others, improving patient engagement with services, continuity of care, providing positive feedback in consultations and goal setting.

Conclusion

We identified a range of factors which can be incorporated in to the design, delivery and evaluation of services to reduce cardiovascular risk for people with severe mental illnesses in primary care. The next step is determining the clinical and cost effectiveness of primary care based interventions for lowering cardiovascular risk in people with severe mental illnesses, and evaluating the most important components of such interventions.     

Determinants of Unlawful File Sharing: A Scoping Review

We employ a scoping review methodology to consider and assess the existing evidence on the determinants of unlawful file sharing (UFS) transparently and systematically. Based on the evidence, we build a simple conceptual framework to model the psychological decision to engage in UFS, purchase legally or do nothing. We identify social, moral, experiential, technical, legal and financial utility sources of the decision to purchase or to file share. They interact in complex ways. We consider the strength of evidence within these areas and note patterns of results. There is good evidence for influences on UFS within each of the identified determinants, particularly for self-reported measures, with more behavioral research needed. There are also indications that the reasons for UFS differ across media; more studies exploring media other than music are required.     

Influenza Forecasting in Human Populations: A Scoping Review

Forecasts of influenza activity in human populations could help guide key preparedness tasks. We conducted a scoping review to characterize these methodological approaches and identify research gaps. Adapting the PRISMA methodology for systematic reviews, we searched PubMed, CINAHL, Project Euclid, and Cochrane Database of Systematic Reviews for publications in English since January 1, 2000 using the terms “influenza AND (forecast* OR predict*)”, excluding studies that did not validate forecasts against independent data or incorporate influenza-related surveillance data from the season or pandemic for which the forecasts were applied. We included 35 publications describing population-based (N = 27), medical facility-based (N = 4), and regional or global pandemic spread (N = 4) forecasts. They included areas of North America (N = 15), Europe (N = 14), and/or Asia-Pacific region (N = 4), or had global scope (N = 3). Forecasting models were statistical (N = 18) or epidemiological (N = 17). Five studies used data assimilation methods to update forecasts with new surveillance data. Models used virological (N = 14), syndromic (N = 13), meteorological (N = 6), internet search query (N = 4), and/or other surveillance data as inputs. Forecasting outcomes and validation metrics varied widely. Two studies compared distinct modeling approaches using common data, 2 assessed model calibration, and 1 systematically incorporated expert input. Of the 17 studies using epidemiological models, 8 included sensitivity analysis. This review suggests need for use of good practices in influenza forecasting (e.g., sensitivity analysis); direct comparisons of diverse approaches; assessment of model calibration; integration of subjective expert input; operational research in pilot, real-world applications; and improved mutual understanding among modelers and public health officials.     

Prognostic Indicators for Gastrointestinal Stromal Tumors: A Review

Gastrointestinal stromal tumors (GISTs) are potentially malignancies that can occur anywhere in the digestive tract. Tyrosine kinase inhibitors (TKIs) such as imatinib have proven effective since the discovery of KIT and PDGFRA. The current version of NCNN, ESMO and EURACAN guidelines recognized that the three main prognostic factors are the mitotic rate, tumor size and tumor site. In addition, tumor rupture is also recognized as an independent risk factor. However, recent evidence shows that various types of gene mutations are associated with prognosis, and influencing factors such as gastrointestinal bleeding and high Ki67 index have been associated with poor prognosis. It shows that the current risk classification is still insufficient and controversial. With the emergence of more and more lack mutation in KIT/PDGFRA GISTs (KIT/PDGFRA wild-type GISTs) or drug resistance genes, primary and secondary drug resistance problems are caused, which makes the treatment of late or metastatic GIST face challenges. Therefore, this article will review the clinicopathological characteristics of GIST, the special molecular subtypes and other factors that may affect prognosis. We will also explore reliable prognostic markers for better postoperative management and improve the prognosis of patients with GIST.     

Testicular Tissue Cryopreservation and Ethical Considerations: A Scoping Review

Testicular tissue cryopreservation (TTCP) aims to preserve the future option of genetic reproduction for prepubescent cancer patients who are at risk of infertility as a result of their cancer therapies. This technology is experimental and currently only offered in the research context. As TTCP moves towards becoming more widely available, it is imperative that healthcare providers recognize the complex ethical issues surrounding this technology. This scoping review study identifies and assesses the range and depth of ethical concerns related to this testicular tissue cryopreservation technology. At present, no such scoping review of ethical concerns exists in the TTCP literature. The forty-three full-text articles included in this study yielded twenty-two different ethical considerations discussed in relation to TTCP. It was observed that these ethical considerations fit within a mainstream Principlism approach to bioethics. Accordingly, there are ethical gaps in the TTCP literature that can be identified with alternative moral lenses. In particular, it was found that ethical concerns related to context and relational aspects of identity were absent in nearly all ethical examinations of TTCP. Furthermore, only 9 per cent of articles reviewed in this study focused primarily on the ethics of TTCP, thus demonstrating a need for further in depth ethical analyses of this technology. The results of this study are important for supporting the ethical provision of TTCP and can contribute to policy and guideline development. The findings of this study demonstrate the need for greater depth and diversity in analyses of ethical considerations related to this technology.     

基于医疗服务绩效信息透明的质量促进效果研究综述

利用描述性综述的方法,总结近10年来医疗服务绩效信息透明对医疗质量促进效果,根据纳入排除标准检索Web of Knowledge、Pubmed等数据库,最终纳入31篇密切相关文献。结果表明,国外一般通过医疗报告卡或网站向公众公开医疗服务绩效信息,改善了医疗服务行为,但对病人选择服务提供者和临床结果的改善作用有限。我国应制定相关政策,推动医疗服务绩效信息向更广泛的使用者公开,引导病人利用医疗服务绩效信息选择医疗服务提供者。     

Diabetes Self-Management and Education of People Living with Diabetes: A Survey in Primary Health Care in Muscat Oman

Background

Although the prevalence of type 2 diabetes in Oman is high and rising, information on how people were self-managing their disease has been lacking. The objective of this study was therefore to assess diabetes self-management and education (DSME) among people living with type 2 diabetes in Oman.

Methods

A questionnaire survey was conducted in public primary health care centres in Muscat. Diabetes self-management and education was assessed by asking how patients recognized and responded to hypo- and hyperglycaemia, and if they had developed strategies to maintain stable blood glucose levels. Patients'' demographic information, self-treatment behaviours, awareness of potential long-term complications, and attitudes concerning diabetes management were also recorded. Associations between these factors and diabetes self-management and education were analysed.

Results

In total, 309 patients were surveyed. A quarter (26%, n = 83) were unaware how to recognize hypoglycaemia or respond to it (26%, n = 81). Around half (49%, n = 151), could not recognize hyperglycaemia and more than half could not respond to it (60%, n = 184). Twelve percent (n = 37) of the patients did not have any strategies to stabilize their blood glucose levels. Patients with formal education generally had more diabetes self-management and education than those without (p<0.001), as had patients with longer durations of diabetes (p<0.01). Self-monitoring of blood glucose was practiced by 38% (n = 117) of the patients, and insulin was used by 22% (n = 67), of which about one third independently adjusted dosages. Patients were most often aware of complications concerning loss of vision, renal failure and cardiac problems. Many patients desired further health education.

Conclusions

Many patients displayed dangerous diabetes self-management and education knowledge gaps. The findings suggest a need for improving knowledge transfer to people living with diabetes in the Omani clinical setting.     

Identifying Drivers of Overall Satisfaction in Patients Receiving HIV Primary Care: A Cross-Sectional Study

Objective

This study seeks to understand the drivers of overall patient satisfaction in a predominantly low-income, ethnic-minority population of HIV primary care patients. The study’s primary aims were to determine 1) the component experiences which contribute to patients’ evaluations of their overall satisfaction with care received, and 2) the relative contribution of each component experience in explaining patients’ evaluation of overall satisfaction.

Methods

We conducted a cross-sectional study of 489 adult patients receiving HIV primary care at two clinics in Houston, Texas, from January 13–April 21, 2011. The participation rate among eligible patients was 94%. The survey included 15 questions about various components of the care experience, 4 questions about the provider experience and 3 questions about overall care. To ensure that the survey was appropriately tailored to our clinic population and the list of component experiences reflected all aspects of the care experience salient to patients, we conducted in-depth interviews with key providers and clinic staff and pre-tested the survey instrument with patients.

Results

Patients’ evaluation of their provider correlated the strongest with their overall satisfaction (standardized β = 0.445, p<0.001) and accounted for almost half of the explained variance. Access and availability, like clinic hours and ease of calling the clinic, also correlated with overall satisfaction, but less strongly. Wait time and parking, despite receiving low patient ratings, did not correlate with overall satisfaction.

Conclusions

The patient-provider relationship far exceeds other component experiences of care in its association with overall satisfaction. Our study suggests that interventions to improve overall patient satisfaction should focus on improving patients’ evaluation of their provider.     

医师绩效评价指标体系构建策略描述性系统综述

利用描述性系统综述的方法,系统梳理医师绩效评价指标体系构建策略,以PubMed等数据库为数据源,经过检索、筛选最终确定15篇密切相关文献,分析后知,主要有医院信息系统法、信息熵法、平衡计分卡、关键绩效指标法、全面绩效计分卡、360度绩效考核法和医师质量评价等方法,但是多源于企业管理,应用于医师绩效评价仍面临着诸多问题和挑战。     

Quality of Life of People Living with HIV/AIDS: A Cross-Sectional Study in Zhejiang Province,China

Health-related quality of life (HRQOL) has become a concept commonly used in the related research. Using the World Health Organization Quality of Life Questionnaire for Brief Version (WHOQOL-BREF), this study evaluated the Quality of Life (QOL) of people living with HIV/AIDS (PLWHA) in Zhejiang province, China, and assessed the influences of demographic, laboratory and disease-related variables on QOL. This cross-sectional study was conducted among PLWHA aged ≥ 18 years in Taizhou municipality, Zhejiang province, China, between August 1 and October 31, 2014. A multiple linear regression model was used to analyze the influential factors. Of 403 subjects, 72.48% were male, 72.46% had received a high- school or above education, 94.79% were of Han ethnicity, and 65.51% were non farmers. The total score of QOL was 15.99±1.99. The scores of QOL in physiological, psychological, social relation, and environmental domains were 14.99 ±2.25, 14.25 ±2.12, 13.22 ±2.37, and 13.31 ±1.99 respectively. Except the total score of QOL and the score of environmental domain (p<0.05), the scores in other domains had no significant difference with the results of the national norm level. The multiple linear regression model identified the physical domain related factors to be age (β = -0.045), CD4 count (β = 0.002), and ART adherence(β = 1.231). And it also showed that psychological domain related factors included CD4 count (β = 0.002) and WHO clinical stage (β = -0.437); social domain related factors included WHO clinical stage (β = -0.704) and ART adherence (β = 1.177); while environmental domain related factors included WHO clinical stage (β = -0.538), educational status(β = 0.549) and ART adherence(β = 1.078).Those who are young, with higher level of education, higher CD4 count and good access and adherence of ART, are likely to have better QOL among PLWHA in Zhejiang province. This suggests that in addition to ART, many other factors should be taken into consideration to improve the QOL of PLWHA. The relatively lower scores the subjects received in social relation and environmental domains also suggest that social relation and environmental interventions need to be strengthened.     

Integrating HIV Care into Primary Care Services: Quantifying Progress of an Intervention in South Africa

Background

Integration of human immunodeficiency virus (HIV) care into primary care services is one strategy proposed to achieve universal access to antiretroviral treatment (ART) for HIV-positive patients in high burden countries. There is a need for controlled studies of programmes to integrate HIV care with details of the services being integrated.

Methods

A semi-quantitative questionnaire was developed in consultation with clinic staff, tested for internal consistency using Cronbach''s alpha coefficients and checked for inter-observer reliability. It was used to conduct four assessments of the integration of HIV care into referring primary care clinics (mainstreaming HIV) and into the work of all nurses within ART clinics (internal integration) and the integration of pre-ART and ART care during the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) trial in South Africa. Mean total integration and four component integration scores at intervention and control clinics were compared using one way analysis of variance (ANOVA). Repeated measures ANOVA was used to analyse changes in scores during the trial.

Results

Cronbach''s alpha coefficients for total integration, pre-ART and ART integration and mainstreaming HIV and internal integration scores showed good internal consistency. Mean total integration, mainstreaming HIV and ART integration scores increased significantly at intervention clinics by the third assessment. Mean pre-ART integration scores were almost maximal at the first assessment and showed no further change. There was no change in mean internal integration score.

Conclusion

The questionnaire developed in this study is a valid tool with potential for monitoring integration of HIV care in other settings. The STRETCH trial interventions resulted in increased integration of HIV care, particularly ART care, by providing HIV care at referring primary care clinics, but had no effect on integrating HIV care into the work of all nurses with the ART clinic.     

Companion Animals in Natural Disasters: A Scoping Review of Scholarly Sources

During a disaster, people may make evacuation decisions based on their companion animal’s welfare, therefore exposing themselves, their companion animals, and emergency responders to increased risk for injury or death. The loss and suffering of companion animals in disasters causes deep distress, diminishing people’s capacity to rebuild their lives. This scoping review presents scholarly research studies and reviews relating to people and their companion animals in the context of disasters, with an aim of informing researchers, policymakers, and practitioners and providing direction for future research. Using the Arksey and O’Malley framework, articles in scholarly journals from 2004 to 2014 are discussed. Analysis included 38 articles: 20 research studies, 12 reviews, and 6 editorials. Findings revealed 2 central themes: companion animals as a risk factor to human health and safety and companion animals being “at risk” themselves. An emerging theme was “responsibility”: Who is responsible for companion animals in disasters and how? Understanding the implications of human–nonhuman animal relationships for disaster response and having a broader public consensus on what is owed to animals at times of emergency are important to community preparedness and resilience.     

Systematic Review of TST Responses in People Living with HIV in Under-Resourced Settings: Implications for Isoniazid Preventive Therapy

Background

People living with HIV (PLWH) who have positive tuberculin skin tests (TST) benefit from isoniazid preventive therapy (IPT) whereas those testing TST-negative do not. Revised World Health Organization guidelines explicitly state that assessment of TST is not a requirement for initiation of IPT. However, it is not known what proportions of patients will benefit from IPT if implemented without targeting according to TST status. We therefore determined the proportions of PLWH who test TST-positive.

Methodology/Principal Findings

We systematically reviewed the literature published between January 1990 and February 2012 to determine the proportions of patients without active tuberculosis attending HIV care services in low and middle-income countries who tested TST-positive (≥5 mm induration). Proportions were also determined for different CD4 count strata. Data from 19 studies with 9,478 PLWH from sub-Saharan Africa, Asia and Central and South America were summarized. The vast majority were not receiving antiretroviral therapy (ART). A sub-analysis was conducted of 5 studies (5,567 subjects) from high TB prevalence countries of PLWH with negative TB screens attending HIV care and treatment settings for whom CD4 stratified data were available. The median proportion of PLWH testing TST-positive overall was 22.8% (range, 19.5–32.6%). The median (range) proportions with CD4 cell counts of <200, 200–499 or ≥500 cells/µL who tested positive were 12.4% (8.2–15.3%), 28.4% (20.1–36.9%) and 37.4% (31.3–56.3%), respectively. Heterogeneity in the data precluded calculation of pooled summary estimates.

Conclusions/Significance

In most settings, if IPT is administered to PLWH pre-ART without assessment of TST status, only a minority of those treated are likely to benefit, especially among those with the lowest CD4 cell counts. This may be inefficient use of resources and cost-effectiveness analyses should take this into account. Local knowledge of TST response rates may help inform policies. New simple means of identifying those who will benefit from IPT are needed to permit appropriate targeting of this intervention.