Suitability of three indicators measuring the quality of coordination within hospitals

<p>Abstract</p> <p>Background</p> <p>Coordination within hospitals is a major attribute of medical care and influences quality of care. This study tested the validity of 3 indicators covering two key aspects of coordination: the transfer of written information between professionals (medical record content, radiology exam order) and the holding of multidisciplinary team meetings during treatment planning.</p> <p>Methods</p> <p>The study was supervised by the French health authorities (COMPAQH project). Data for the three indicators were collected in a panel of 30 to 60 volunteer hospitals by 6 Clinical Research Assistants. The metrological qualities of the indicators were assessed: (i) Feasibility was assessed using a grid of 19 potential problems, (ii) Inter-observer reliability was given by the kappa coefficient () and internal consistency by Cronbach's alpha test, (iii) Discriminatory power was given by an analysis of inter-hospital variability using the Gini coefficient as a measure of dispersion.</p> <p>Results</p> <p>Overall, 19281 data items were collected and analyzed. All three indicators presented acceptable feasibility and reliability (, 0.59 to 0.97) and showed wide differences among hospitals (Gini, 0.08 to 0.11), indicating that they are suitable for making comparisons among hospitals.</p> <p>Conclusion</p> <p>This set of 3 indicators provides a proxy measurement of coordination. Further research on the indicators is needed to find out how they can generate a learning process. The medical record indicator has been included in the French national accreditation procedure for healthcare organisations. The two other indicators are currently being assessed for inclusion.</p

The importance of genetic testing in adolescent-onset steroid-resistant nephrotic syndrome - Case report

Approximately 10-20% of children and 40% of adults with idiopathic nephrotic syndrome are steroid resistant and progress to end-stage renal disease requiring dialysis or renal transplantation. In these cases, renal histology typically shows focal segmental glomerulosclerosis. Mutations in NPHS1, NPHS2, WT1, CD2AP and ACTN4 genes located on different chromosomes, expressed by glomerular podocytes, have been identified in patients with steroid-resistant nephrotic syndrome. The authors report two cases of adolescent-onset steroid-resistant nephrotic syndrome. Both cases had similar clinical and histopathological manifestations, with different prognosis and evolution due to different mechanisms leading to proteinuria: an acquired and a genetic form. The first case, a 16 year old girl presented the onset of the disease with massive, generalized edema, secondary hypothyroidism and high blood pressure. Evolution was favorable under cyclosporine therapy. The second case, a 13-years-old adolescent girl, presented an insidious onset of the disease with mild edema. Genetic testing revealed a mutation in the WT1 gene. The patient developed end-stage kidney failure eight months after the onset of the disease and following kidney transplant had a favorable evolution. Histological examination of the renal biopsy specimen showed focal segmental glomerulosclerosis in both cases. Conclusions: Genetic forms of nephrotic syndrome do not respond to immunosuppressive therapy and may progress to end-stage renal disease, but after kidney transplantation relapse is not expected, in contrast to the immune form. The early genetic diagnosis in steroid-resistant nephrotic syndrome is time-consuming, but is important for proper clinical management of the patients, prognosis and genetic counseling of the families

Multicenter trial of one HLA-DR–matched or mismatched blood transfusion prior to cadaveric renal transplantation

Multicenter trial of one HLA-DR–matched or mismatched blood transfusion prior to cadaveric renal transplantation.BackgroundThe beneficial effect of blood transfusions before cadaveric renal transplantation on allograft survival, although previously well documented, has become controversial in light of their adverse effects. Recently, it has been suggested that their clinical benefits are due to HLA-DR sharing between the blood donor and recipient.MethodsIn this prospective study, 144 naive patients were randomly assigned to receive one unit of blood matched for one-HLA-DR antigen (N = 49), or one unit of mismatched blood (N = 48), or to remain untransfused (N = 47). Graft survival and acute rejection rate were analyzed in 106 cadaveric renal allograft recipients receiving the same immunosuppressive protocol.ResultsGraft survival was similar in the three groups at one and five years: 91.7 and 80% in untransfused patients, 90.3 and 79.3% in patients transfused with one DR-antigen–matched unit, and 92.3 and 83.7% in patients transfused with HLA-mismatched blood. The difference in the incidence of six-month post-transplant acute rejections was not statistically significant in the three groups: 12 out of 36, 33.3% in nontransfused patients; 6 out of 31, 19.4% in patients transfused with one DR-matched blood; and 13 out of 39, 33.3% in patients transfused with mismatched blood.ConclusionThe results of our prospective randomized trial showed that in a population of naive patients, one transfusion mismatched or matched for one HLA-DR antigen given prior to renal transplantation had no significant effect on the incidence and severity of acute rejection, and did not influence overall long-term graft outcome. Considering the potentially deleterious adverse effects of blood transfusions, the costs, and the considerable logistical efforts required to select and type blood donors, such a procedure cannot be recommended in a routine practice for patients awaiting cadaveric kidney transplantation

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Impacts of Organizational Context on Quality Improvement: don't forget internal management !

International audienceTo the Editor, In a recent article, Glasgow et al assessed the impacts of organizational context on quality improvement (QI). In their study of organizational characteristics of 100 hospitals participating in a national QI collaborative, they did not find any predictive associations with QI performance. Using a different approach, we conducted a study of 505 French hospitals that are subject to mandatory annual measurements of quality indicators in a national program aimed at promoting continuous quality improvement (CQI). This program is driven by the French Ministry of Health, the French Health Authority, and our research group (COMPAQ-HPST). From an analysis of the literature, we developed a theoretical frame that ranged potential factors of success for a CQI program along 2 axes. One concerned contextual factors (eg, staff stability, QI information), which covered the same organizational characteristics as described by Glasgow et al. The other included managerial factors (eg, managers use quality indicator results to define the hospi-tal's strategy, managers favor multiprofessional commitment when analyzing quality indicator results), which do not seem to have been considered in that article. Seventeen factors were identified and considered to be relevant by a panel of 22 health care professionals, using a consensus method. The relevance of these 17 factors was thereafter confirmed in 505 hospitals by assessing the correlation between the presence/absence of these factors and the results of 3 quality indicators (quality of patient medical records, pain assessment, and delay in sending information at patient discharge). A factorial analysis showed that the managerial axis included 6 factors and the contextual axis included 11. Cronbach α for the 2 axes were .78 and .82, respectively. A multivariate analysis showed a link between managerial score and the results of an indicator assessing the quality of patients' medical records (P = .02) and an indicator measuring the delay in sending information at patients' discharge (P = .03). We believe that managerial capacity is an important factor in the success of QI programs and should be analyzed more precisely

Identification of appropriate and potentially avoidable emergency department referrals in a tertiary cancer care center

International audiencePURPOSE:Referrals to the Emergency Department can be distressing to patients with advanced cancer and may be a non-optimizing health care service. We aimed to describe the appropriateness and potential avoidability of Emergency Department referrals in a tertiary cancer care center where only physician referrals are allowed.METHODS:We prospectively reviewed the electronic medical charts of patients consecutively checked into the Emergency Department in August 2015. The appropriateness of referrals was assessed using a nationally validated classification (Classification Clinique des Malades aux Urgences) and local criteria. Potentially avoidable referrals were assessed using international classifications (Institute for Healthcare Improvement State Action on Avoidable Rehospitalizations diagnostic tool according to Kosecoff's criteria) and local criteria.RESULTS:We included 500 referrals related to 423 patients. The mean age was 59 years, and 74% of cancers were progressive. The referrals were appropriate in 61% of cases. They were deemed potentially avoidable "with a high likelihood" in 33.4% (CI95% [29.3-37.5]) of cases, potentially avoidable "with a moderate likelihood" in 14.4% (CI95% [11.3-17.5]) of cases, and "non-avoidable" in 52% (CI95% [47.6-56.4]) of cases. Opportunities to avoid referrals after an index stay involved this hospital stay or discharge process in 66 cases (28%), the follow-up period in 59 cases (25%), or both in 66 cases (28%).CONCLUSIONS:Potentially avoidable ED referrals are common in patients with cancer. These potentially avoidable ED referrals underline the importance of several domains of care coordination.Comment inResponse to "Identification of appropriate and potentially avoidable emergency department referrals in a tertiary cancer care center" by Duflos et al. [Support Care Cancer. 2018]Response to the response by Lahbib et al. to "Identification of appropriate and potentially avoidable emergency department referrals in a tertiary cancer care center" by Duflos et al. [Support Care Cancer. 2018

Should payment for performance depend on mortality?

International audienceThe introduction of the Hospital Value Based Purchasing (HVBP) programme, as shown recently by Jose F Figueroa and colleagues, did not improve 30 day mortality of Medicare beneficiaries admitted to US hospitals for three incentivised conditions. We agree with the authors’ conclusion that an “appropriate mix of quality metrics and incentives to improve patient outcomes” has yet to be identified.The programme was designed to promote better clinical outcomes for hospital patients and to improve their experience of care during hospital stays. However, if reducing mortality was the primary objective, a specific set of indicators should have been selected from relevant practice and organisational guidelines, which was not the case when the programme was designed. The absence of HVBP’s impact on mortality is therefore not surprising.In their conclusion Figueroa and colleagues say, “Nations considering similar pay for performance programs may want to consider alternative models.” This raises a question: should payment depend on achieving a decrease in mortality rates? The primary objective of pay for performance programmes could still be the development and maintenance of continuous quality improvement (CQI) programmes based on relevant process indicators to assess critical steps in patient management, such as the effective use of checklists in surgical procedures. These process indicators are apt to detect dangerous misconduct, less susceptible to bias, and more actionable.However, a problem remains: such CQI programmes in hospitals rely on a limited number of people repeatedly trying to motivate a large number of health professionals who are insensitive to the benefits of CQI. Instead of diverting the small percentage of budget devoted to pay for performance programmes it could be more profitable, for patients, to think of a better use for this money

Restoration of the K and F Components of the Solar Corona from LASCO-C2 Images over 24 Years [1996 – 2019]

International audienceWe present a photometrically accurate restoration of the K- and F-coronae from white-light images obtained over 24 years [1996 – 2019] by the Large-Angle Spectrometric COronagraph (LASCO-C2) onboard the Solar and Heliospheric Observatory (SOHO). The procedure starts with the data set of unpolarized images of 512 × 512 pixels produced by the polarimetric analysis of the routine C2 polarization sequences (Lamy et al., Solar Phys. 295, 89, 2020) in which the F-corona, the instrumental stray light, and possible remnants of the K-corona due to the imperfect polarimetric separation are entangled. Disentangling these components requires a complex procedure organized in three stages, each composed of several steps. Stage 1 establishes the distinct variations of the radiance of these components with the Sun–SOHO distance, and generate a new data set of median images calculated for each Carrington rotation. Stage 2 achieves the restoration of a set of 36 stray-light images that account for the temporal variation of the stray-light pattern, in particular those associated with the periodic roll maneuvers of SOHO, which started in 2003. Stage 3 achieves the restoration of the F-corona, and a time series of daily images is generated. Combining these images with the set of stray-light images allowed us to process the whole set of routine LASCO-C2 images of 1024 × 1024 pixels (approximately 626,000 images) and to produce calibrated, high-resolution images of the K-corona. The two sets of images of the K-corona, that produced by polarimetric separation of 512 × 512 pixels images and that presently produced by subtraction, are in excellent photometric agreement. We extend our past conclusions that the temporal variation of the integrated radiance of the K-corona tracks the solar activity over Solar Cycles 23 and 24, and that it is highly correlated with the temporal variation of the total magnetic field. The behaviors of the integrated radiance during the last few years of the declining phases of Solar Cycles 23 and 24 are remarkably similar, reaching the same base level and leading to a duration of 11.0 years for the latter cycle, in agreement with that derived from sunspots

Precision of Composite Performance Scores

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