Learning from MARQuIS: future direction of quality and safety in hospital care in the European Union.

This article summarises the significant lessons to be drawn from, and the policy implications of, the findings of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) project--a part of the suite of research projects intended to support policy established by the European Commission through its Sixth Framework Programme. The article first reviews the findings of MARQuIS and their implications for healthcare providers (and particularly for hospitals), and then addresses the broader policy implications for member states of the European Union (EU) and for the commission itself. Against the background of the European Commission's Seventh Framework Programme, it then outlines a number of future areas for research to inform policy and practice in quality and safety in Europe. The article concludes that at this stage, a unique EU-wide quality improvement system for hospitals does not seem to be feasible or effective. Because of possible future community action in this field, attention should focus on the use of existing research on quality and safety strategies in healthcare, with the aim of combining soft measures to accelerate mutual learning. Concrete measures should be considered only in areas for which there is substantial evidence and effective implementation can be ensured

Do European hospitals have quality and safety governance systems and structures in place?

Internal systems for quality and safety were assessed in 89 hospitals in six European states, by external teams using standardised criteria and procedures, as part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) project. The assessments were made primarily to identify the current use of quality management systems in the sample hospitals, and also to demonstrate a potential tool for comparable assessment of hospitals in general. The large majority of the hospitals had a formal, documented infrastructure to manage quality and safety, but a significant minority had no designated mission, programme or coordination. In two-thirds of hospitals, the governing body was active in defining policy and programmes for improvement, and received reports on quality, safety and patient satisfaction at least once a year. The brief on-site assessments identified systematic variations, within and between countries, in structures and processes of governance and to document the uptake of best practice. Unacceptable variations in practice could be reduced, to the benefit of consumers and providers, by developing and publishing basic organisational standards relevant to all European states. The simple assessment criteria designed for this project could be developed into a practical tool for self-assessment, peer review or benchmarking of hospitals across national borders. This assessment, combined with explicit, relevant and achievable standards, could provide a vehicle to promote the voluntary uptake of best practice and consistency in quality and safety among hospitals in Europe

Quality requirements for cross-border care in Europe: a qualitative study of patients’, professionals’ and healthcare financiers’ views

In the past decade the issue of patient mobility has emerged on the European health policy agenda. Although the volume of patients crossing borders to obtain healthcare is low, it is increasing continuously and, due to its legal, financial and medical implications, has generated considerable interest among health policy and other decision makers. However, there is little information available on the safety and patient-centredness of cross-border care and neither governments nor citizens have an explicit basis for comparing healthcare delivery in Europe. This study investigated the viewpoints of patients, professionals and healthcare financiers on the safety and patient-centredness of cross-border care. Qualitative interviews were carried out during 2005 and early 2006 with 40 patients, 30 professionals (doctors, nurses and managers) and 3 healthcare-financing bodies. Although cross-border care has become a common issue in many European countries, there remain uncertainties on the side of each of the parties addressed-patients, professionals and financiers-with regard to the provision of cross-border care. One of the most striking results of this project is the current lack of research on systematic knowledge on the quality of cross-border care. Many of the issues identified through this research may have a potential impact on the quality and safety of cross-border care and will support further investigation and help shape the health policy agenda on patients crossing borders in European Union countries

Impact of quality strategies on hospital outputs

Context: This study was part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project on patients crossing borders, a study to investigate quality improvement strategies in healthcare systems across the European Union (EU). Aim: To explore the association between the implementation of quality improvement strategies in hospitals and hospitals' success in meeting defined quality requirements that are considered intermediate outputs of the care process. Methods: Data regarding the implementation of seven quality improvement strategies (accreditation, organisational quality management programmes, audit and internal assessment of clinical standards, patient safety systems, clinical practice guidelines, performance indicators and systems for obtaining patients' views) and four dimensions of outputs (clinical, safety, patient-centredness and cross-border patient-centredness) were collected from 389 acute care hospitals in eight EU countries using a web-based questionnaire. In a second phase, 89 of these hospitals participated in an on-site audit by independent surveyors. Pearson correlation and linear regression models were used to explore associations and relations between quality improvement strategies and achievement of outputs. Results: Positive associations were found between six internal quality improvement strategies and hospital outputs. The quality improvement strategies could be reasonably subsumed under one latent index which explained about half of their variation. The analysis of outputs concluded that the outputs can also be considered part of a single construct. The findings indicate that the implementation of internal as well as external quality improvement strategies in hospitals has beneficial effects on the hospital outputs studied here. Conclusion: The implementation of internal quality improvement strategies as well as external assessment systems should be promoted

Volume and diagnosis: an approach to cross-border care in eight European countries

Objectives: Mobility of patients is a pertinent issue on the European Union's agenda. This study aimed to estimate the volume and main diagnoses of cross-border care in eight European countries, in order to provide policy makers with background information about the nature of patient mobility in Europe. Methods: This article reports the combined findings from three independent studies that compiled self-reported information on admissions data and main diagnoses from more than 200 hospitals in eight European countries. Results: The average volume of cross-border patients accounted for less than 1% of total admissions in the hospitals studied here. Diseases of the circulatory system (mainly acute myocardial infarction) and fractures were the most common reasons for hospitalisation of European patients abroad. Deliveries and other diagnoses related to pregnancy, pneumonia, appendicitis and other diseases of the digestive system, aftercare procedures, and disorders of the eye and adnexa were also common diagnoses for this population. Conclusions: Hospitals should reinforce their efforts to adapt the care provided to the needs of foreign patients in treatment areas that cover the most frequent pathologies identified in this populatio

Tryptophan depletion affects compulsive behaviour in rats:strain dependent effects and associated neuromechanisms

RATIONALE: Compulsive behaviour, present in different psychiatric disorders, such as obsessive-compulsive disorder, schizophrenia and drug abuse, is associated with altered levels of monoamines, particularly serotonin (5-hydroxytryptamine) and its receptor system. OBJECTIVES: The present study investigated whether 5-HT manipulation, through a tryptophan (TRP) depletion by diet in Wistar and Lister Hooded rats, modulates compulsive drinking in schedule-induced polydipsia (SIP) and locomotor activity in the open-field test. The levels of dopamine, noradrenaline, serotonin and its metabolite were evaluated, as well as the 5-HT(2A) and 5-HT(1A) receptor binding, in different brain regions. METHODS: Wistar rats were selected as high (HD) or low (LD) drinkers according to their SIP behaviour, while Lister hooded rats did not show SIP acquisition. Both strains were fed for 14 days with either a TRP-free diet (T−) or a TRP-supplemented diet (T+) RESULTS: The TRP depletion diet effectively reduced 5-HT levels in the frontal cortex, amygdala and hippocampus in both strains of rats. The TRP-depleted HD Wistar rats were more sensitive to 5-HT manipulation, exhibiting more licks on SIP than did the non-depleted HD Wistar rats, while the LD Wistar and the Lister Hooded rats did not exhibit differences in SIP. In contrast, the TRP-depleted Lister Hooded rats increased locomotor activity compared to the non-depleted rats, while no differences were found in the Wistar rats. Serotonin 2A receptor binding in the striatum was significantly reduced in the TRP-depleted HD Wistar rats. CONCLUSIONS: These results suggest that alterations of the serotonergic system could be involved in compulsive behaviour in vulnerable populations

Brain structural changes during juvenile fibromyalgia: relationships with pain, fatigue and functional disability

Objective: Juvenile fibromyalgia (FM) is a prevalent chronic pain condition affecting children and adolescents worldwide during a critical period of brain development. To date, no published studies have addressed the pathophysiology of juvenile FM. This study was undertaken to characterize gray matter volume (GMV) alterations in juvenile FM patients for the first time, and to investigate their functional and clinical relevance. Methods: Thirty-four female adolescents with juvenile FM and 38 healthy adolescents underwent a structural magnetic resonance imaging examination and completed questionnaires assessing core juvenile FM symptoms. Using voxel-based morphometry, we assessed between-group GMV differences and associations between GMV and functional disability, fatigue, and pain interference in juvenile FM. We also studied whether validated brain patterns predicting pain, cognitive control, or negative emotion were amplified/attenuated in juvenile FM patients and whether structural alterations reported in adult FM were replicated in adolescents with juvenile FM. Results: Compared to controls, juvenile FM patients showed GMV reductions in the anterior midcingulate cortex (aMCC) region (family-wise error corrected P [PFWE-corr ] = 0.04; estimated with threshold-free cluster enhancement [TFCE]; n = 72) associated with pain. Within the juvenile FM group, patients reporting higher functional disability had larger GMV in inferior frontal regions (PFWE-corr = 0.006; TFCE estimated; n = 34) linked to affective, self-referential, and language-related processes. Last, GMV reductions in juvenile FM showed partial overlap with findings in adult FM, specifically for the anterior/posterior cingulate cortices (P = 0.02 and P = 0.03, respectively; n = 72). Conclusion: Pain-related aMCC reductions may be a structural hallmark of juvenile FM, whereas alterations in regions involved in emotional, self-referential, and language-related processes may predict disease impact on patients' well-being. The partial overlap between juvenile and adult FM findings strengthens the importance of early symptom identification and intervention to prevent the transition to adult forms of the disease

Is the maturity of hospitals' quality improvement systems associated with measures of quality and patient safety?

UNLABELLED: ABSTRACT: BACKGROUND: Previous research addressed the development of a classification scheme for quality improvement systems in European hospitals. In this study we explore associations between the 'maturity' of the hospitals' quality improvement system and clinical outcomes. METHODS: The maturity classification scheme was developed based on survey results from 389 hospitals in eight European countries. We matched the hospitals from the Spanish sample (113 hospitals) with those hospitals participating in a nation-wide, voluntary hospital performance initiative. We then compared sample distributions and explored associations between the 'maturity' of the hospitals' quality improvement system and a range of composite outcomes measures, such as adjusted hospital-wide mortality, -readmission, -complication and -length of stay indices. Statistical analysis includes bivariate correlations for parametrically and non-parametrically distributed data, multiple robust regression models and bootstrapping techniques to obtain confidence-intervals for the correlation and regression estimates. RESULTS: Overall, 43 hospitals were included. Compared to the original sample of 113, this sample was characterized by a higher representation of university hospitals. Maturity of the quality improvement system was similar, although the matched sample showed less variability. Analysis of associations between the quality improvement system and hospital-wide outcomes suggests significant correlations for the indicator adjusted hospital complications, borderline significance for adjusted hospital readmissions and non-significance for the adjusted hospital mortality and length of stay indicators. These results are confirmed by the bootstrap estimates of the robust regression model after adjusting for hospital characteristics. CONCLUSIONS: We assessed associations between hospitals' quality improvement systems and clinical outcomes. From this data it seems that having a more developed quality improvement system is associated with lower rates of adjusted hospital complications. A number of methodological and logistic hurdles remain to link hospital quality improvement systems to outcomes. Further research should aim at identifying the latent dimensions of quality improvement systems that predict quality and safety outcomes. Such research would add pertinent knowledge regarding the implementation of organizational strategies related with quality of care outcomes

Investigating organizational quality improvement systems, patient empowerment, organizational culture, professional involvement and the quality of care in European hospitals: the 'Deepening our Understanding of Quality Improvement in Europe (DUQuE)' project

BACKGROUND: Hospitals in European countries apply a wide range of quality improvement strategies. Knowledge of the effectiveness of these strategies, implemented as part of an overall hospital quality improvement system, is limited. METHODS/DESIGN: We propose to study the relationships among organisational quality improvement systems, patient empowerment, organisational culture, professionals' involvement with the quality of hospital care, including clinical effectiveness, patient safety and patient involvement. We will employ a cross-sectional, multi-level study design in which patient-level measurements are nested in hospital departments, which are in turn nested in hospitals in different EU countries. Mixed methods will be used for data collection, measurement and analysis. Hospital/care pathway level constructs that will be assessed include external pressure, hospital governance, quality improvement system, patient empowerment in quality improvement, organisational culture and professional involvement. These constructs will be assessed using questionnaires. Patient-level constructs include clinical effectiveness, patient safety and patient involvement, and will be assessed using audit of patient records, routine data and patient surveys. For the assessment of hospital and pathway level constructs we will collect data from randomly selected hospitals in eight countries. For a sample of hospitals in each country we will carry out additional data collection at patient-level related to four conditions (stroke, acute myocardial infarction, hip fracture and delivery). In addition, structural components of quality improvement systems will be assessed using visits by experienced external assessors. Data analysis will include descriptive statistics and graphical representations and methods for data reduction, classification techniques and psychometric analysis, before moving to bi-variate and multivariate analysis. The latter will be conducted at hospital and multilevel. In addition, we will apply sophisticated methodological elements such as the use of causal diagrams, outcome modelling, double robust estimation and detailed sensitivity analysis or multiple bias analyses to assess the impact of the various sources of bias. DISCUSSION: Products of the project will include a catalogue of instruments and tools that can be used to build departmental or hospital quality and safety programme and an appraisal scheme to assess the maturity of the quality improvement system for use by hospitals and by purchasers to contract hospitals