Health Care System Performance
Assessing Diabetes Care Quality
Standardized measures were used to assess nationwide changes in the quality of diabetes care between 1988 and 2002. The National Health and Nutrition Examination Survey and the Behavioral Risk Factor Surveillance System, both based on patient-reported data, found a 3.9 percent decrease in persons with poor glycemic control and 21. 9 percent increase in persons with fair or good lipid control. Annual lipid testing, dilated eye examinations, and foot examinations also increased. Despite these and other improvements in diabetes processes of care and intermediate outcomes, two of five people with diabetes still have poor LDL cholesterol control, one of three still has poor blood pressure control, and one of five still has poor glycemic control. J. B. Saaddine et al. (2006) Improvements in Diabetes Processes of Care and Intermediate Outcomes: United States, 1988–2002. Annals of Internal Medicine 144, 465–474.
Sociodemographics: Who's Receiving Recommended Care?
Medical record and telephone interview data from randomly sampled people living in 12 communities were used to assess the extent to which health care quality varies among sociodemographic groups. The authors found that participants overall received 54.9 percent of recommended care and there was only moderate variation in quality-of-care scores among sociodemographic subgroups. Women received slightly better scores than men and participants below the age of 31 years received slightly better scores than those over the age of 64 years. Blacks and Hispanics received slightly better scores than whites, and those with annual household incomes over $50,000 received slightly better scores than those with incomes of less than $15,000. They conclude that quality improvement programs focused solely on reducing disparities among sociodemographic subgroups might be missing larger opportunities to improve care. S. M. Asch et al. (2006) Who Is at Greatest Risk for Receiving Poor-Quality Health Care? New England Journal of Medicine 354, 1147–1156.
Dissatisfaction, Problems Higher Among Minority Children with Needs
The National CSHCN (children with special health care needs) Survey, conducted from 2000 to 2002, was used to examine satisfaction with care and ease of health care services use and assess any racial/ethnic disparities. The authors found black and Hispanic parents were significantly more likely than white parents to be dissatisfied with care (13 percent and 16 percent vs. 7 percent) and to report problems with ease of service use (35 percent and 34 percent vs. 23 percent). They conclude that reducing language barriers, promoting insurance coverage and family-centered care, and improving the ease of service use among minority children with special needs has the potential to reduce the observed disparities. E. M. Ngui and G. Flores (2006) Satisfaction With Care and Ease of Using Health Care Services Among Parents of Children With Special Health Care Needs: The Roles of Race/Ethnicity, Insurance, Language, and Adequacy of Family-Centered Care. Pediatrics 117, 1184–1196.
Quality Tools in Practice
Hospital QI: Implementation Affects Outcomes
A cross-sectional study of 1,784 community hospitals examined the association between quality improvement (QI) implementation in hospitals and six hospital-level indicators of clinical quality. It found that multiple hospital unit involvement in QI efforts is associated with worse values on hospital-level quality indicators. Also, the percentage of a hospital's staff and senior managers participating in formally organized QI teams is associated with better values on quality indicators, but the percentage of physicians participating in QI teams is not associated with better values. The authors conclude that the scope of QI implementation in hospitals is significantly associated with hospital-level quality indicators, but the direction of the association varies. B. J. Weiner et al. (2006) Quality Improvement Implementation and Hospital Performance on Quality Indicators. Health Services Research 41, 307–334.
Hospital Governance and Quality
Interviews with chief executive officers (CEOs) and board chairpersons at 30 hospitals located in 14 states were used to assess the role of hospital governance in quality improvement. The author found CEOs and board chairs' knowledge of landmark Institute of Medicine (IOM) quality reports to be "remarkably low," yet hospital governance was well attuned to public reporting of quality information. Also, a mild association was found between board engagement in quality and hospital performance, as defined by a composite heart failure, heart attack, and pneumonia measure. The author concludes that hospital board engagement can be enhanced by increasing the board's quality education, improving the framing of the quality agenda, providing more incentives for quality improvement, and focusing more on patients. M. S. Joshi (2006) Getting the Board on Board: Engaging Hospital Boards in Quality and Patient Safety. Joint Commission Journal on Quality and Patient Safety 32, 179–187.
Error Identification and Prevention
Evaluating Medical Devices
The use of medical devices often directly contributes to medical errors. Because it is difficult to change existing devices, the best opportunity for improving medical device safety is during the purchasing process. However, most hospital personnel are not familiar with the usability evaluation methods designed to identify aspects of a user interface that do not support intuitive and safe use. The authors reviewed the operating manuals for five volumetric infusion pumps from three manufacturers as a proxy for evaluation of the usability principles of the actual medical devices. They identified "minimize memory load" as the most frequently violated principle, with 65 violations. They conclude that manual review can complement more formal usability evaluation methods and be used to select a subset of devices for more extensive and formal testing. J. P. Turley et al. (2006) Operating Manual-Based Usability Evaluation of Medical Devices: An Effective Patient Safety Screening Method. Joint Commission Journal on Quality and Patient Safety 32, 214–220.
Medication Errors at Admission and Discharge
Unintended medication variances at the time of hospital admission and discharge are common. A study of 60 patients enrolled at admission to a Canadian community hospital found that 60 percent had at least one unintended variance and 18 percent had at least one clinically important unintended variance. While usual clinical practice did not identify any of these variances, 75 percent of the clinical important variances were intercepted by a medication reconciliation process before patient harm occurred. The authors conclude that medication reconciliation can be a useful method for identifying and rectifying medication errors at times of transition and warrants broader evaluation. T. Vira et al. (2006) Reconcilable Differences: Correcting Medication Errors at Hospital Admission and Discharge. Quality and Safety in Health Care 15, 122–126.
Older Adults
Using Geriatric Care Guidelines to Assess Quality
Current approaches to assessing the quality of diabetes care do not account for older patients' heterogeneity. The authors compared current quality assessment approaches with a stratified approach based on geriatric care guidelines. They found that using a stratified approach to assess the quality of diabetes care led to distinct care conclusions for older patients with and without markers of diminished health. The proportion of sicker patients achieving their specified glucose and systolic blood pressure goals generally was high, whereas the proportion of healthier patients achieving their goals remained low. (Under general population goals only a small proportion of patients met these targets). The authors conclude that acknowledging patient heterogeneity could help ensure the clinical relevance of quality assessment and improvement efforts for older patients. E. S. Huang et al. (2006) Implications of New Geriatric Diabetes Care Guidelines for the Assessment of Quality of Care in Older Patients. Medical Care 44, 373–377.