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Rehman Y, Bala M, Rehman N, Agarwal A, Koperny M, Crandon H, Abdullah R, Hull A, Makhdami N, Grodecki S, Wrzosek A, Lesniak W, Evaniew N, Ashoorion V, Wang L, Couban R, Drew B, Busse JW. Predictors of Recovery Following Lumbar Microdiscectomy for Sciatica: A Systematic Review and Meta-Analysis of Observational Studies. Cureus 2023; 15:e39664. [PMID: 37388594 PMCID: PMC10307033 DOI: 10.7759/cureus.39664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 07/01/2023] Open
Abstract
Chronic post-surgical pain is reported by up to 40% of patients after lumbar microdiscectomy for sciatica, a complaint associated with disability and loss of productivity. We conducted a systematic review of observational studies to explore factors associated with persistent leg pain and impairments after microdiscectomy for sciatica. We searched eligible studies in MEDLINE, Embase, and CINAHL that explored, in an adjusted model, predictors of persistent leg pain, physical impairment, or failure to return to work after microdiscectomy for sciatica. When possible, we pooled estimates of association using random-effects models using the Grading of Recommendations Assessment, Development, and Evaluation approach. Moderate-certainty evidence showed that the female sex probably has a small association with persistent post-surgical leg pain (odds ratio (OR) = 1.15, 95% confidence interval (CI) = 0.63 to 2.08; absolute risk increase (ARI) = 1.8%, 95% CI = -4.7% to 11.3%), large association with failure to return to work (OR = 2.79, 95% CI = 1.27 to 6.17; ARI = 10.6%, 95% CI = 1.8% to 25.2%), and older age is probably associated with greater postoperative disability (β = 1.47 points on the 100-point Oswestry Disability Index for every 10-year increase from age (>/=18 years), 95% CI = -4.14 to 7.28). Among factors that were not possible to pool, two factors showed promise for future study, namely, legal representation and preoperative opioid use, which showed large associations with worse outcomes after surgery. The moderate-certainty evidence showed female sex is probably associated with persistent leg pain and failure to return to work and that older age is probably associated with greater post-surgical impairment after a microdiscectomy. Future research should explore the association between legal representation and preoperative opioid use with persistent pain and impairment after microdiscectomy for sciatica.
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Affiliation(s)
- Yasir Rehman
- Health Research Methodology, McMaster University, Hamilton, CAN
| | - Malgorzata Bala
- Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Krakow, POL
| | - Nadia Rehman
- Health Research Methods, Impact and Evidence, McMaster University, Hamilton, CAN
| | | | - Magdalena Koperny
- Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Krakow, POL
| | - Holly Crandon
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, CAN
| | - Ream Abdullah
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, CAN
| | - Alexandra Hull
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, CAN
| | | | | | - Anna Wrzosek
- Interdisciplinary Intensive Care, Jagiellonian University, Krakow, POL
| | | | | | - Vahid Ashoorion
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, CAN
| | - Li Wang
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, CAN
| | - Rachel Couban
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, CAN
| | - Brian Drew
- Neurosurgery, McMaster University, Hamilton, CAN
| | - Jason W Busse
- Health Research Methodology, McMaster University, Hamilton, CAN
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Kara P, Valentin JB, Mainz J, Johnsen SP. Composite measures of quality of health care: Evidence mapping of methodology and reporting. PLoS One 2022; 17:e0268320. [PMID: 35552561 PMCID: PMC9098058 DOI: 10.1371/journal.pone.0268320] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 04/27/2022] [Indexed: 11/19/2022] Open
Abstract
Background Quality indicators are used to quantify the quality of care. A large number of quality indicators makes assessment of overall quality difficult, time consuming and impractical. There is consequently an increasing interest for composite measures based on a combination of multiple indicators. Objective To examine the use of different approaches to construct composite measures of quality of care and to assess the use of methodological considerations and justifications. Methods We conducted a literature search on PubMed and EMBASE databases (latest update 1 December 2020). For each publication, we extracted information on the weighting and aggregation methodology that had been used to construct composite indicator(s). Results A total of 2711 publications were identified of which 145 were included after a screening process. Opportunity scoring with equal weights was the most used approach (86/145, 59%) followed by all-or-none scoring (48/145, 33%). Other approaches regarding aggregation or weighting of individual indicators were used in 32 publications (22%). The rationale for selecting a specific type of composite measure was reported in 36 publications (25%), whereas 22 papers (15%) addressed limitations regarding the composite measure. Conclusion Opportunity scoring and all-or-none scoring are the most frequently used approaches when constructing composite measures of quality of care. The attention towards the rationale and limitations of the composite measures appears low. Discussion Considering the widespread use and the potential implications for decision-making of composite measures, a high level of transparency regarding the construction process of the composite and the functionality of the measures is crucial.
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Affiliation(s)
- Pinar Kara
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Psychiatry, Aalborg University Hospital, Aalborg, Denmark
- * E-mail:
| | - Jan Brink Valentin
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jan Mainz
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Psychiatry, Aalborg University Hospital, Aalborg, Denmark
- Department for Community Mental Health, University of Haifa, Haifa, Israel
- Department of Health Economics, University of Southern Denmark, Odense, Denmark
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Identifying Performance Outliers for Stroke Care Based on Composite Score of Process Indicators: an Observational Study in China. J Gen Intern Med 2020; 35:2621-2628. [PMID: 32462572 PMCID: PMC7459034 DOI: 10.1007/s11606-020-05923-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 05/11/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Variability in the quality of stroke care is widespread. Identifying performance-based outlier hospitals based on quality indicators (QIs) has become a common practice. OBJECTIVES To develop a tool for identifying performance-based outlier hospitals based on risk-adjusted adherence rates of process indicators. DESIGN Hospitals were classified into five-level outliers based on the observed-to-expected ratio and P value. The composite quality score was derived by summation of the points for each indicator for each hospital, and associations between outlier status and outcomes were determined. PARTICIPANTS Patients diagnosed with acute ischemic stroke, January 1, 2011-May 31, 2017. INTERVENTION N/A MAIN OUTCOME MEASURES: Independence at discharge (the modified Rankin Scale = 0-2). KEY RESULTS A total of 501,132 patients from 519 hospitals were identified. From 0.39 to 19.65% of hospitals were identified as high outliers according to various QIs. Composite quality scores ranged from - 20 to 16. Providers that were high outliers based on QI2, QI8, QI9, and QI11 had higher independent rates. For composite quality score, each point increase corresponded to an 8% increase in the odds of independent rate. CONCLUSION Nationwide variation in the quality of acute stroke care exists at the hospital level. Variability in the quality of stroke care can be captured by our proposed quality score. Applying this quality score as a benchmarking tool could provide audit-level feedback to policymakers and hospitals to aid quality improvement.
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Wilhelm D, Lohmann J, De Allegri M, Chinkhumba J, Muula AS, Brenner S. Quality of maternal obstetric and neonatal care in low-income countries: development of a composite index. BMC Med Res Methodol 2019; 19:154. [PMID: 31315575 PMCID: PMC6637560 DOI: 10.1186/s12874-019-0790-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 06/27/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In low-income countries, studies demonstrate greater access and utilization of maternal and neonatal health services, yet mortality rates remain high with poor quality increasingly scrutinized as a potential point of failure in achieving expected goals. Comprehensive measures reflecting the multi-dimensional nature of quality of care could prove useful to quality improvement. However, existing tools often lack a systematic approach reflecting all aspects of quality considered relevant to maternal and newborn care. We aim to address this gap by illustrating the development of a composite index using a step-wise approach to evaluate the quality of maternal obstetric and neonatal healthcare in low-income countries. METHODS The following steps were employed in creating a composite index: 1) developing a theoretical framework; 2) metric selection; 3) imputation of missing data; 4) initial data analysis 5) normalization 6) weighting and aggregating; 7) uncertainty and sensitivity analysis of resulting composite score; 8) and deconstruction of the index into its components. Based on this approach, we developed a base composite index and tested alternatives by altering the decisions taken at different stages of the construction process to account for missing values, normalization, and aggregation. The resulting single composite scores representing overall maternal obstetric and neonatal healthcare quality were used to create facility rankings and further disaggregated into sub-composites of quality of care. RESULTS The resulting composite scores varied considerably in absolute values and ranges based on method choice. However, the respective coefficients produced by the Spearman rank correlations comparing facility rankings by method choice showed a high degree of correlation. Differences in method of aggregation had the greatest amount of variation in facility rankings compared to the base case. Z-score standardization most closely aligned with the base case, but limited comparability at disaggregated levels. CONCLUSIONS This paper illustrates development of a composite index reflecting the multi-dimensional nature of maternal obstetric and neonatal healthcare. We employ a step-wise process applicable to a wide range of obstetric quality of care assessment programs in low-income countries which is adaptable to setting and context. In exploring alternative approaches, certain decisions influencing the interpretation of a given index are highlighted.
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Affiliation(s)
- Danielle Wilhelm
- Heidelberg Institute of Global Health, Ruprecht-Karls Universität Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Julia Lohmann
- Heidelberg Institute of Global Health, Ruprecht-Karls Universität Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Ruprecht-Karls Universität Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Jobiba Chinkhumba
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Private Bag 360, Chichiri, Blantyre 3 Malawi
| | - Adamson S. Muula
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Private Bag 360, Chichiri, Blantyre 3 Malawi
| | - Stephan Brenner
- Heidelberg Institute of Global Health, Ruprecht-Karls Universität Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
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Rao AR, Clarke D. Exploring relationships between medical college rankings and performance with big data. BIG DATA ANALYTICS 2019. [DOI: 10.1186/s41044-019-0040-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Ngantcha M, Le-Pogam MA, Calmus S, Grenier C, Evrard I, Lamarche-Vadel A, Rey G. Hospital quality measures: are process indicators associated with hospital standardized mortality ratios in French acute care hospitals? BMC Health Serv Res 2017; 17:578. [PMID: 28830422 PMCID: PMC5568353 DOI: 10.1186/s12913-017-2534-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 08/14/2017] [Indexed: 01/24/2023] Open
Abstract
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. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2534-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marcus Ngantcha
- Inserm, CépiDc (Epidemiology center on medical causes of death), Kremlin-Bicêtre, France.
| | - Marie-Annick Le-Pogam
- Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital (CHUV), Lausanne University (UNIL), Lausanne, Switzerland
| | - Sophie Calmus
- Haute Autorité de santé (HAS), Service des indicateurs pour l'amélioration de la qualité et de la sécurité des Soins (SIPAQSS), Saint-Denis La Plaine, France
| | - Catherine Grenier
- Haute Autorité de santé (HAS), Service des indicateurs pour l'amélioration de la qualité et de la sécurité des Soins (SIPAQSS), Saint-Denis La Plaine, France
| | - Isabelle Evrard
- Haute Autorité de santé (HAS), Service des indicateurs pour l'amélioration de la qualité et de la sécurité des Soins (SIPAQSS), Saint-Denis La Plaine, France
| | - Agathe Lamarche-Vadel
- Inserm, CépiDc (Epidemiology center on medical causes of death), Kremlin-Bicêtre, France.,Université Paris Sud, Kremlin-Bicêtre, France
| | - Grégoire Rey
- Inserm, CépiDc (Epidemiology center on medical causes of death), Kremlin-Bicêtre, France.
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Bebb OJ, Hall M, Gale CP. Why report outcomes when process measures will suffice? EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2017; 3:1-3. [PMID: 28927182 PMCID: PMC7614830 DOI: 10.1093/ehjqcco/qcw050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Owen John Bebb
- Leeds Institute of Cardiovascular and Metabolic Medicine, Worsley Building, Level 11, Clarendon Way, University of Leeds, Leeds, LS2 9JT, UK
- York Teaching Hospital NHS Foundation Trust, Wigginton Road, York, YO31 8HE, UK
| | - Marlous Hall
- Leeds Institute of Cardiovascular and Metabolic Medicine, Worsley Building, Level 11, Clarendon Way, University of Leeds, Leeds, LS2 9JT, UK
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, Worsley Building, Level 11, Clarendon Way, University of Leeds, Leeds, LS2 9JT, UK
- York Teaching Hospital NHS Foundation Trust, Wigginton Road, York, YO31 8HE, UK
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Schiele F, Gale CP, Bonnefoy E, Capuano F, Claeys MJ, Danchin N, Fox KAA, Huber K, Iakobishvili Z, Lettino M, Quinn T, Rubini Gimenez M, Bøtker HE, Swahn E, Timmis A, Tubaro M, Vrints C, Walker D, Zahger D, Zeymer U, Bueno H. Quality indicators for acute myocardial infarction: A position paper of the Acute Cardiovascular Care Association. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:34-59. [DOI: 10.1177/2048872616643053] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Francois Schiele
- University Hospital of Besancon, EA3920 University of Franche-Comté, Besançon, France
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds; York Teaching Hospital NHS Foundation Trust, York, UK
| | - Eric Bonnefoy
- Unité de soins intensifs cardiologiques, Hôpital Cardiologique Louis-Pradel, Bron, France
| | | | - Marc J Claeys
- Cardiology Department, University Hospital Antwerp, Edegem, Belgium
| | - Nicolas Danchin
- Assistance Publique-Hôpitaux de Paris (AP-HP); Hôpital Européen Georges Pompidou (HEGP), Department of Cardiology, Paris, France; Université Paris-Descartes, Paris, France
| | - Keith AA Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria
| | | | | | - Tom Quinn
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Maria Rubini Gimenez
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel
| | - Hans E Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Eva Swahn
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Sweden
| | - Adam Timmis
- National Institute for Health Research Biomedical Research Unit, Barts Heart Centre, London, UK
| | | | | | - David Walker
- East Sussex Healthcare, Conquest Hospital, Hastings, UK
| | - Doron Zahger
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Uwe Zeymer
- Klinikum Ludwigshafen and Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | - Hector Bueno
- Centro Nacional de InvestigacionesCardiovasculares (CNIC), Cardiology Department, Hospital Universitario 12 de Octubre, and Universidad Complutense de Madrid, Madrid, Spain
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Chung KP, Chen LJ, Chang YJ, Chang YJ. Can composite performance measures predict survival of patients with colorectal cancer? World J Gastroenterol 2014; 20:15805-15814. [PMID: 25400466 PMCID: PMC4229547 DOI: 10.3748/wjg.v20.i42.15805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 03/24/2014] [Accepted: 05/19/2014] [Indexed: 02/07/2023] Open
Abstract
AIM: To assess the relationship between long-term colorectal patient survival and methods of calculating composite performance scores.
METHODS: The Taiwan Cancer Database was used to identify patients who underwent bowel resection for colorectal adenocarcinoma between 2003 and 2004. Patients were assigned to one of three cohorts based on tumor staging: cohort 1, colon cancer stage < III; cohort 2, colon cancer stage III; cohort 3, rectal cancer. A composite performance score (CPS) was calculated for each patient using five different aggregating methods, including all-or-none, 70% standard, equal weight, analytic hierarchy process (AHP), and principal component analysis (PCA) algorithms. The relationships between CPS and five-year overall, disease-free, and disease-specific survivals were evaluated by a Cox proportional hazards model. A goodness-of-fit analysis for all five methods was performed using Akaike’s information criterion.
RESULTS: A total of 3272 colorectal cancer patients (cohort 1, 1164; cohort 2, 790; cohort 3, 1318 patients) with a mean age of 65 years were enrolled in the study. Bivariate correlation analysis showed that CPS values from the equal weight method were highly correlated with those from the AHP method in all cohorts (all P < 0.05). Multivariate Cox hazards analysis showed that CPS values derived from equal weight and AHP methods were significantly associated with five-year survivals of patients in cohorts 1 and 2 (all P < 0.05). In these cohorts, higher CPS values suggested a higher probability of five-year survival. However, CPS values derived from the all-or-none method did not show any significant process-outcome relationship in any cohort. Goodness-of-fit analyses showed that CPS values derived from the PCA method were the best fit to the Cox proportional hazards model, whereas the values from the all-or-none model showed the poorest fit.
CONCLUSION: CPS values may highlight process-outcome relationships for patients with colorectal cancer in addition to evaluating quality of care performance.
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An evaluation of composite indicators of hospital acute myocardial infarction care: a study of 136,392 patients from the Myocardial Ischaemia National Audit Project. Int J Cardiol 2013; 170:81-7. [PMID: 24182669 DOI: 10.1016/j.ijcard.2013.10.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 09/03/2013] [Accepted: 10/07/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Hospital acute myocardial infarction (AMI) care is increasingly evaluated using composite quality scores. We investigated the influence of three aggregation methods for an AMI indicator on mortality and hospital rank. METHODS AND RESULTS We studied 136,392 patients discharged alive from 199 hospitals with AMI recorded in the Myocardial Ischaemia National Audit Project, between 01/01/2008 and 31/12/2009. A composite of prescription of aspirin, thienopyridine inhibitor, β-blocker, angiotensin converting enzyme inhibitor, HMG CoA reductase enzyme inhibitor and enrolment in cardiac rehabilitation at discharge was aggregated as opportunity based (OBCS), weighted opportunity-based (WOBCS) and all-or-nothing (ANCS) scores. We quantified adjusted 30-day, 6-month and 1-year mortality rates and hospital performance rank. Median (IQR) scores were OBCS: 95.0% (3.5), WOBCS: 94.7% (0.8) and ANCS: 80.9% (11.8). The three methods affected the proportion of hospitals outside 99.8% credible limits of the national median (OBCS: 52.2%, WOBCS: 64.3% and ANCS: 37.7%) and hospital rank. Each 1% increase in composite score was significantly associated with a 1 to 3% and a 4% reduction in 6-month and 1-year mortality, respectively. However, the ANCS had fewer cases and no significant association with 30-day mortality. CONCLUSIONS A hospital composite score, incorporating 6 aspects of AMI care, was significantly inversely associated with mortality. However, composite aggregation method influenced hospital rank, number of cases available for analysis and size of the association with all-cause mortality, with the ANCS performing least well. The use and choice of composite scores in hospital AMI quality improvement requires careful evaluation.
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Leleu H, Capuano F, Nitenberg G, Travental L, Minvielle E. Hospital performance based on treatment delays: comparison of ranking methods. BMJ Qual Saf 2013; 23:73-7. [PMID: 23922404 DOI: 10.1136/bmjqs-2013-001833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Reducing time-to-care is crucial in many acute and chronic diseases. Quality indicators based on target delays derived from guidelines are used to compare hospital performance but there is no accepted methodology for comparing performance when no target delay has been established. AIM To explore by different statistical methods the uncertainty in hospital comparisons that are based on delay indicators, when no target delay is available. METHODS Data for hospital door-to-needle time were extracted from a 2010 study of 1699 patients in 57 hospitals with ST-elevated myocardial infarction. We determined whether the times in each hospital were statistically different from the overall mean time or the median time for all hospitals by (i) one-way analysis of variance (ANOVA), (ii) non-parametric ANOVA with Nelson-Hsu adjustment (ANOVA R) and (iii) the proportional hazard model (PHM). We also tested for the assumptions underlying the methods: normal distribution for ANOVA, homogeneity of variances (homoscedasticity) for ANOVA and ANOVA R, and proportionality for PHM. RESULTS Door-to-needle times were available for 889 patients in 44 hospitals. Data distribution was not Gaussian. Test assumptions were verified for ANOVA R (homoscedasticity) for one data subset (>48-h times (48H) excluded) and for PHM (proportionality) for two data subsets (48H or >95th percentile (P95) times excluded). The same five significantly better performers were identified in each case (although ANOVA R missed one). ANOVA R (48H) identified two significantly poorer performers, PHM (48H) identified three and PHM (P95) just one. Poorer performers differed according to method. CONCLUSIONS The tested statistical methods yielded broadly similar results but no method was truly satisfactory. A transparency statement should therefore always specify the ranking method used to compare hospital performance.
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Affiliation(s)
- Henri Leleu
- COMPAQ-HPST, Institut Gustave Roussy, , Villejuif, France
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Schiele F, Capuano F, Loirat P, Desplanques-Leperre A, Derumeaux G, Thebaut JF, Gardel C, Grenier C. Hospital Case Volume and Appropriate Prescriptions at Hospital Discharge After Acute Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2013; 6:50-7. [DOI: 10.1161/circoutcomes.112.967133] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
In acute myocardial infarction, the relationship between volume and quality indicators (QIs) is poorly documented. Through a nationwide assessment of QIs at discharge repeated for 3 years, we aimed to quantify the relationship between volume and QIs in survivors after acute myocardial infarction.
Methods and Results—
Almost all healthcare centers in France participated. Medical records were randomly selected. Data collection was performed by an independent group. QIs for acute myocardial infarction were defined by an expert consensus group as appropriate prescription at discharge of aspirin, clopidogrel, β-blocker, statin, and an angiotensin-converting enzyme inhibitor in patients with left ventricular ejection fraction <0.40. A composite QI was calculated through the use of the all-or-none method. Volume was classified into 7 categories based on the number of admissions for acute myocardial infarctions in 2008 (centers with <10 acute myocardial infarctions were excluded). Odds ratios adjusted for age and sex with 95% confidence interval for volume categories were calculated by use of logistic regression for each QI. Temporal changes were tested in centers that participated in all 3 campaigns. A total of 46 390 records were examined: 18 159 in 2008, 12 837 in 2009, and 15 394 in 2010. Two hundred ninety-one centers were eligible for the temporal analysis. There was a significant increase between 2008 and 2009 in appropriate prescription of antiplatelet agents, β-blockers, angiotensin-converting enzyme inhibitor, statins at discharge, and the composite indicator. Similarly, a significant increase was observed between 2009 and 2010 in appropriate prescription of angiotensin-converting enzyme inhibitor and β-blockers and in the composite QI. Compared with a volume of >300, a significantly lower rate of all QIs was observed in centers with the lowest volume. Odds ratios progressively decreased with increasing volume. Despite a significant increase in the composite QI over the 3 years, a significant relationship persisted between volume and quality of care.
Conclusions—
Analysis of QIs at discharge demonstrates the existence of a relationship between volume and appropriate prescriptions at discharge. Centers with the highest volume perform better on quality measures than centers with lower volumes. Temporal analysis over 3 consecutive years confirms this relationship and shows that it persists despite improvement in QIs between 2008 and 2010.
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Affiliation(s)
- François Schiele
- From the French Society of Cardiology, Paris (F.S.); University Hospital Jean Minjoz, Besançon (F.S.); Haute Autorité de Santé, Saint Denis (F.C., P.L., A.D.-L., C. Gardel, C. Grenier); National College of French Cardiologists, Paris (G.D.); and National Professional Board of Cardiology, Paris (J.-F.T.), France
| | - Frédéric Capuano
- From the French Society of Cardiology, Paris (F.S.); University Hospital Jean Minjoz, Besançon (F.S.); Haute Autorité de Santé, Saint Denis (F.C., P.L., A.D.-L., C. Gardel, C. Grenier); National College of French Cardiologists, Paris (G.D.); and National Professional Board of Cardiology, Paris (J.-F.T.), France
| | - Philippe Loirat
- From the French Society of Cardiology, Paris (F.S.); University Hospital Jean Minjoz, Besançon (F.S.); Haute Autorité de Santé, Saint Denis (F.C., P.L., A.D.-L., C. Gardel, C. Grenier); National College of French Cardiologists, Paris (G.D.); and National Professional Board of Cardiology, Paris (J.-F.T.), France
| | - Armelle Desplanques-Leperre
- From the French Society of Cardiology, Paris (F.S.); University Hospital Jean Minjoz, Besançon (F.S.); Haute Autorité de Santé, Saint Denis (F.C., P.L., A.D.-L., C. Gardel, C. Grenier); National College of French Cardiologists, Paris (G.D.); and National Professional Board of Cardiology, Paris (J.-F.T.), France
| | - Geneviève Derumeaux
- From the French Society of Cardiology, Paris (F.S.); University Hospital Jean Minjoz, Besançon (F.S.); Haute Autorité de Santé, Saint Denis (F.C., P.L., A.D.-L., C. Gardel, C. Grenier); National College of French Cardiologists, Paris (G.D.); and National Professional Board of Cardiology, Paris (J.-F.T.), France
| | - Jean-François Thebaut
- From the French Society of Cardiology, Paris (F.S.); University Hospital Jean Minjoz, Besançon (F.S.); Haute Autorité de Santé, Saint Denis (F.C., P.L., A.D.-L., C. Gardel, C. Grenier); National College of French Cardiologists, Paris (G.D.); and National Professional Board of Cardiology, Paris (J.-F.T.), France
| | - Christine Gardel
- From the French Society of Cardiology, Paris (F.S.); University Hospital Jean Minjoz, Besançon (F.S.); Haute Autorité de Santé, Saint Denis (F.C., P.L., A.D.-L., C. Gardel, C. Grenier); National College of French Cardiologists, Paris (G.D.); and National Professional Board of Cardiology, Paris (J.-F.T.), France
| | - Catherine Grenier
- From the French Society of Cardiology, Paris (F.S.); University Hospital Jean Minjoz, Besançon (F.S.); Haute Autorité de Santé, Saint Denis (F.C., P.L., A.D.-L., C. Gardel, C. Grenier); National College of French Cardiologists, Paris (G.D.); and National Professional Board of Cardiology, Paris (J.-F.T.), France
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14
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Georges JL, Ben-Hadj I, Gibault-Genty G, Blicq E, Aziza JP, Ben-Jemaa K, Moro J, Koukabi M, Livarek B. [Accuracy of the door-to-balloon time for assessing the result of the interventional reperfusion strategy in acute ST-segment elevation myocardial infarction]. Ann Cardiol Angeiol (Paris) 2011; 60:244-251. [PMID: 21978820 DOI: 10.1016/j.ancard.2011.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2011] [Accepted: 07/24/2011] [Indexed: 05/31/2023]
Abstract
BACKGROUND In patients with acute ST-segment elevation myocardial infarction (STEMI), recent clinical guidelines recommend that primary percutaneous coronary intervention (PCI) should be performed within 90min of first medical contact or 45min after admission in cathlab. The Door-to-Balloon time (D2B) is widely used to measure the performance of interventional centres. AIM OF THE STUDY To analyze the time to reperfusion in a consecutive series of STEMI patients referred for primary PCI, and to evaluate the clinical accuracy of D2B in primary PCI. METHODS From January 2007 to March 2008, 177 patients were admitted within 12hours of a STEMI in our institution, and 87 were referred for a direct coronary angiography for primary PCI (47 by mobile medical emergency unit, 40 by the emergency department of the institution). RESULTS The median time from first medical contact to balloon inflation (M2B) was 135min [IQR 112-183]. Recommended times were fulfilled in a minority of patients (M2B<90min: 9%,<120min: 34%). Median cathlab D2B was 51min [IQR 44-65], and was less than 45min in 34% of patients. No differences for times to reperfusion within cathlab were found between in- and off-time hours. M2B and D2B were unavailable in 23 patients (26%), because of a spontaneous TIMI 3 flow reperfusion without indication for immediate PCI in 20 patients, contra-indication for PCI in two (distal occlusion, culprit vessel diameter less than 2mm), and failure in occlusion crossing by the guide-wire in one patient. In contrast, first medical contact- or door-to-reperfusion times, assessed by a TIMI 3 flow without no-reflow in culprit artery, were available in 95% of patients, and were shorter than M2B or D2B, respectively. CONCLUSION Although it is a feasible and reproducible process performance measure, D2B time is weakly associated with the outcome of the interventional reperfusion strategy in acute STEMI. This measure should be associated with an outcome performance measure, such as the rate of TIMI 3 flow achieved by primary PCI, or replaced by the Door-to-TIMI 3 flow reperfusion time.
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Affiliation(s)
- J-L Georges
- Service de cardiologie, hôpital André-Mignot, Le-Chesnay cedex, France.
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15
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Eapen ZJ, Fonarow GC, Dai D, O'Brien SM, Schwamm LH, Cannon CP, Heidenreich PA, Bhatt DL, Peterson ED, Hernandez AF. Comparison of composite measure methodologies for rewarding quality of care: an analysis from the American Heart Association's Get With The Guidelines program. Circ Cardiovasc Qual Outcomes 2011; 4:610-8. [PMID: 22010200 DOI: 10.1161/circoutcomes.111.961391] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Composite indices of health care performance are an aggregation of underlying individual performance measures and are increasingly being used to rank hospitals. We sought to conduct an observational analysis to determine the influence of the opportunity-based and all-or-none composite performance measures on hospital rankings. METHODS AND RESULTS We examined 194 245 patients hospitalized with acute myocardial infarction between July 2006 and June 2009 from 334 hospitals participating in the Get With The Guidelines--Coronary Artery Disease (GWTG-CAD) quality improvement program. We analyzed hospital opportunity-based and all-or-none composite scores and 30-day risk-standardized all-cause mortality and readmission rates. We found that the median calculated opportunity-based score for these hospitals was 95.5 (interquartile range, 90.4, 98.0). The median all-or-none score was 88.9 (interquartile range, 79.7, 94.4). The 2 scoring methods were significantly correlated with one another (r=0.98, P<0.001). Rankings generated by the two methods were significantly correlated (r=0.93, P<0.001). The two methods had a modest correlation with the 30-day risk-standardized mortality rate (opportunity-based score: r=-0.25, P<0.001; all-or-none score: r=-0.24, P<0.001). Neither composite measure correlated with the 30-day risk-standardized readmission rate. Over time, the number of hospitals new to the top and bottom quintiles of hospital rankings diminished similarly for both composite measures. When including additional performance measures into the composite score, the two methods produced similar changes in hospital rankings. CONCLUSIONS The opportunity-based and all-or-none coronary artery disease composite indices are highly correlated and yield similar ranking of the top and bottom quintiles of hospitals. The two methods provide similarly modest correlations with 30-day mortality, but not readmission.
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Affiliation(s)
- Zubin J Eapen
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
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