Quality Improvement Practices in Academic Emergency Medicine: Perspectives from the Chairs

Objective: To assess academic emergency medicine (EM) chairs’ perceptions of quality improvement (QI) training programs.Methods: A voluntary anonymous 20 item survey was distributed to a sample of academic chairs of EM through the Association of Academic Chairs of Emergency Medicine. Data was collected to assess the percentage of academic emergency physicians who had received QI training, the type of training they received, their perception of the impact of this training on behavior, practice and outcomes, and any perceived barriers to implementing QI programs in the emergency department.Results: The response rate to the survey was 69% (N = 59). 59.3% of respondents report that their hospital has a formal QI program for physicians. Chairs received training in a variety of QI programs. The type of QI program used by respondents was perceived as having no impact on goals achieved by QI (χ2 = 12.382; p = 0.260), but there was a statistically significant (χ2 = 14.383; p = 0.006) relationship between whether or not goals were achieved and academic EM chairs’ perceptions about return on investment for QI training. Only 22% of chairs responded that they have already made changes as a result of the QI training. 78.8% of EM chairs responded that quality programs could have a significant positive impact on their practice and the healthcare industry. Chairs perceived that QI programs had the most potential value in the areas of understanding and reducing medical errors and improving patient flow and throughput. Other areas of potential value of QI include improving specific clinical indicators and standardizing physician care.Conclusion: Academic EM chairs perceived that QI programs were an effective way to drive needed improvements. The results suggest that there is a high level of interest in QI but a low level of adoption of training and implementation.[West J Emerg Med. 2010; 11(5):479-485.

Barriers and Disparities in Emergency Medical Services 911 Calls for Stroke Symptoms in the United States Adult Population: 2009 BRFSS Survey

Introduction: This study examines barriers and disparities in the intentions of American citizens, when dealing with stroke symptoms, to call 911. This study hypothesizes that low socioeconomic populations are less likely to call 911 in response to stroke recognition. Methods: The study is a cross-sectional design analyzing data from the Centers for Disease Control’s 2009 Behavioral Risk Factor Surveillance Survey, collected through a telephone-based survey from 18 states and the District of Columbia. The study identified the 5 most evident stroke-warning symptoms based on those given by the American Stroke Association. We conducted appropriate weighting procedures to account for the complex survey design. Results: A total of 131,988 respondents answered the following question: “If you thought someone was having a heart attack or a stroke, what is the first thing you would do?” A majority of those who said they would call 911 were insured (85.1%), had good health (84.1%), had no stroke history (97.3%), had a primary care physician (PCP) (81.4%), and had no burden of medical costs (84.9%). Those less likely to call 911 were found in the following groups: 65 years or older, men, other race, unmarried, less than or equal to high school degree, less than $25,000 family income, uninsured, no PCP, burden of medical costs, fair/poor health, previous history of strokes, or interaction between burden of medical costs and less than$50,000 family income (p\u3c0.0001 by X2 tests). The only factors significantly associated with “would call 911” were age, sex, race/ethnicity, marital status, and previous history of strokes. Conclusion: Barriers and disparities exist among subpopulations of different socioeconomic statuses. This study suggests that some potential stroke victims could have limited access to EMS services. Greater effort targeting certain populations is needed to motivate citizens to call 911. [West J Emerg Med. 2014;15(2):251–259]

Integrating Lean Six Sigma and discrete-event simulation for shortening the appointment lead-time in gynecobstetrics departments: a case study

Long waiting time to appointment may be a worry for pregnant women, particularly those who need perinatology consultation since it could increase anxiety and, in a worst case scenario, lead to an increase in fetal, infant, and maternal mortality. Treatment costs may also increase since pregnant women with diverse pathologies can develop more severe complications. As a step towards improving this process, we propose a methodological approach to reduce the appointment lead-time in outpatient gynecobstetrics departments. This framework involves combining the Six Sigma method to identify defects in the appointment scheduling process with a discrete-event simulation (DES) to evaluate the potential success of removing such defects in simulation before we resort to changing the real-world healthcare system. To do these, we initially characterize the gynecobstetrics department using a SIPOC diagram. Then, six sigma performance metrics are calculated to evaluate how well the department meets the government target in relation to the appointment lead-time. Afterwards, a cause-and-effect analysis is undertaken to identify potential causes of appointment lead-time variation. These causes are later validated through ANOVA, regression analysis, and DES. Improvement scenarios are next designed and pretested through computer simulation models. Finally, control plans are deployed to maintain the results achieved through the implementation of the DES-Six sigma approach. The aforementioned framework was validated in a public gynecobstetrics outpatient department. The results revealed that mean waiting time decreased from 6.9 days to 4.1 days while variance passed from 2.46 days2 to 1.53 days2

TElehealth in CHronic disease: mixed-methods study to develop the TECH conceptual model for intervention design and evaluation

Objective To develop a conceptual model for effective use of telehealth in the management of chronic health conditions, and to use this to develop and evaluate an intervention for people with two exemplar conditions: raised cardiovascular disease risk and depression. Design The model was based on several strands of evidence: a metareview and realist synthesis of quantitative and qualitative evidence on telehealth for chronic conditions; a qualitative study of patients’ and health professionals’ experience of telehealth; a quantitative survey of patients’ interest in using telehealth; and review of existing models of chronic condition management and evidence-based treatment guidelines. Based on these evidence strands, a model was developed and then refined at a stakeholder workshop. Then a telehealth intervention (‘Healthlines’) was designed by incorporating strategies to address each of the model components. The model also provided a framework for evaluation of this intervention within parallel randomised controlled trials in the two exemplar conditions, and the accompanying process evaluations and economic evaluations. Setting Primary care. Results The TElehealth in CHronic Disease (TECH) model proposes that attention to four components will offer interventions the best chance of success: (1) engagement of patients and health professionals, (2) effective chronic disease management (including subcomponents of self-management, optimisation of treatment, care coordination), (3) partnership between providers and (4) patient, social and health system context. Key intended outcomes are improved health, access to care, patient experience and cost-effective care. Conclusions A conceptual model has been developed based on multiple sources of evidence which articulates how telehealth may best provide benefits for patients with chronic health conditions. It can be used to structure the design and evaluation of telehealth programmes which aim to be acceptable to patients and providers, and cost-effective

An evidence-based approach to the use of telehealth in long-term health conditions: development of an intervention and evaluation through pragmatic randomised controlled trials in patients with depression or raised cardiovascular risk

Background: Health services internationally are exploring the potential of telehealth to support the management of the growing number of people with long-term conditions (LTCs). Aim: To develop, implement and evaluate new care programmes for patients with LTCs, focusing on two common LTCs as exemplars: depression or high cardiovascular disease (CVD) risk. Methods Development: We synthesised quantitative and qualitative evidence on the effectiveness of telehealth for LTCs, conducted a qualitative study based on interviews with patients and staff and undertook a postal survey to explore which patients are interested in different forms of telehealth. Based on these studies we developed a conceptual model [TElehealth in CHronic disease (TECH) model] as a framework for the development and evaluation of the Healthlines Service for patients with LTCs. Implementation: The Healthlines Service consisted of regular telephone calls to participants from health information advisors, supporting them to make behaviour change and to use tailored online resources. Advisors sought to optimise participants’ medication and to improve adherence. Evaluation: The Healthlines Service was evaluated with linked pragmatic randomised controlled trials comparing the Healthlines Service plus usual care with usual care alone, with nested process and economic evaluations. Participants were adults with depression or raised CVD risk recruited from 43 general practices in three areas of England. The primary outcome was response to treatment and the secondary outcomes included anxiety (depression trial), individual risk factors (CVD risk trial), self-management skills, medication adherence, perceptions of support, access to health care and satisfaction with treatment. Trial results Depression trial: In total, 609 participants were randomised and the retention rate was 86%. Response to treatment [Patient Health Questionnaire 9-items (PHQ-9) reduction of ≥ 5 points and score of < 10 after 4 months] was higher in the intervention group (27%, 68/255) than in the control group (19%, 50/270) [odds ratio 1.7, 95% confidence interval (CI) 1.1 to 2.5; p = 0.02]. Anxiety also improved. Intervention participants reported better access to health support, greater satisfaction with treatment and small improvements in self-management, but not improved medication adherence. CVD risk trial: In total, 641 participants were randomised and the retention rate was 91%. Response to treatment (maintenance of/reduction in QRISK®2 score after 12 months) was higher in the intervention group (50%, 148/295) than in the control group (43%, 124/291), which does not exclude a null effect (odds ratio 1.3, 95% CI 1.0 to 1.9; p = 0.08). The intervention was associated with small improvements in blood pressure and weight, but not smoking or cholesterol. Intervention participants were more likely to adhere to medication, reported better access to health support and greater satisfaction with treatment, but few improvements in self-management. The Healthlines Service was likely to be cost-effective for CVD risk, particularly if the benefits are sustained, but not for depression. The intervention was implemented largely as planned, although initial delays and later disruption to delivery because of the closure of NHS Direct may have adversely affected participant engagement. Conclusion: The Healthlines Service, designed using an evidence-based conceptual model, provided modest health benefits and participants valued the better access to care and extra support provided. This service was cost-effective for CVD risk but not depression. These findings of small benefits at extra cost are consistent with previous pragmatic research on the implementation of comprehensive telehealth programmes for LTCs