Bridging the ivory towers and the swampy lowlands; increasing the impact of health services research on quality improvement

Decisions about how to organize and deliver health services are often more complex and seemingly less rational than decisions about what clinical care to provide. The concept of 'Evidence-Based Management', or what might more appropriately be termed 'Evidence-Informed Improvement', does not seem to have captured the hearts and minds of the people responsible for managing health-care provision. Organizational decision-making is more likely to be influenced by political, ideological and pragmatic factors, and by the personal experience of the decision-makers, than by science. Whilst some people would regard the messiness of management decision-making as inevitable, most would accept that decisions could be improved by making greater use of the established health service research evidence, and through a stronger commitment to developing new evidence. Over the last two or more decades the evidence base created by Health Service Researchers has grown in quantity and in quality and yet much of it remains invisible to the people who most need to use it. This paper explores how the disconnect between the traditional 'producers' of research evidence in academia, and the managerial and clinical 'consumers' of that evidence, has contributed to the challenge of embedding an evidence-informed approach to service improvement. The advantages of a closer working relationship between academia and health services are outlined and three approaches to evidence creation and utilization are described which attempt to maximize the influence of scientific evidence on managerial practice

Teaching NeuroImages: Nonfluent variant primary progressive aphasia: A distinctive clinico-anatomical syndrome

A 66-year-old woman presented with 4 years of progressive speech difficulty. She had nonfluent speech with phonemic errors but intact single-word comprehension and object knowledge. Her grammar was impaired in both speech and writing, and she exhibited orofacial apraxia. A clinico-radiologic (see figure) diagnosis of nonfluent variant primary progressive aphasia was made

Teaching Neuro Images: Nonfluent variant primary progressive aphasia: A distinctive clinico-Anatomical syndrome

A 66-year-old woman presented with 4 years of progressive speech difficulty. She had nonfluent speech with phonemic errors but intact single-word comprehension and object knowledge. Her grammar was impaired in both speech and writing, and she exhibited orofacial apraxia. A clinico-radiologic (see figure) diagnosis of nonfluent variant primary progressive aphasia was made

Hospital quality reports in Germany: patient and physician opinion of the reported quality indicators

<p>Abstract</p> <p>Background</p> <p>Starting in 2005, Germany's health law required hospital quality reports to be published every two years by all acute care hospitals. The reports were intended to help patients and physicians make informed choices of hospitals. However, while establishing the quality indicators that form the content of the reports, the information needs of the target groups were not explicitly taken into account. Therefore, the aim of our study was to determine patient and physician opinion of the relevance of the reported quality indicators for choosing or referring to a hospital.</p> <p>Methods</p> <p>Convenience samples of 50 patients and 50 physicians were asked to rate the understandability (patients), suitability (physicians) and relevance (both groups) of a set of 29 quality indicators. The set was drawn from the reports (24 indicators) and supplemented by five indicators commonly used in hospital quality reports. We analysed the differences in patient and physician ratings of relevance of all indicators by applying descriptive statistics, t-tests and Wilcoxon tests.</p> <p>Results</p> <p>Only three indicators were considered not understandable by the interviewed patients and unsuitable by the interviewed physicians. The patients rated 19 indicators as highly or very relevant, whereas the physicians chose 15 indicators. The most relevant indicator for the patients was "qualification of doctors", and for the physicians "volume of specified surgical procedures". Patient and physician rankings of individual indicators differed for 25 indicators. However, three groups of indicators could be differentiated, in which the relevance ratings of patients and physicians differed only within the groups. Four of the five indicators that were added to the existing set of reported indicators ranked in the first or second group ("kindness of staff", "patient satisfaction", "recommendation", and "distance to place of living").</p> <p>Conclusion</p> <p>Most of the content of Germany's hospital quality reports seems to be useful for patients and physicians and influence their choice of hospitals. However, the target groups revealed that approximately one third of the indicators (mostly hospital structural characteristics), were not useful and hence could have been omitted from the reports. To enhance the usefulness of the reports, indicators on patient experiences should be added.</p

An ethical framework for cardiac report cards: a qualitative study

BACKGROUND: The recent proliferation of health care report cards, especially in cardiac care, has occurred in the absence of an ethical framework to guide in their development and implementation. An ethical framework is a consistent and comprehensive theoretical foundation in ethics, and is formed by integrating ethical theories, relevant literature, and other critical information (such as the views of stakeholders). An ethical framework in the context of cardiac care provides guidance for developing cardiac report cards (CRCs) that are relevant and legitimate to all stakeholders. The purpose of this study is to develop an ethical framework for CRCs. METHODS: Delphi technique – 13 panelists: 2 administrators, 2 cardiac nurses, 5 cardiac patients, 2 cardiologists, 1 member of the media, and 1 outcomes researcher. Panelists' views regarding the ethics of CRCs were analyzed and organized into themes. RESULTS: We have organized panelists' views into ten principles that emerged from the data: 1) improving quality of care, 2) informed understanding, 3) public accountability, 4) transparency, 5) equity, 6) access to information 7) quality of information, 8) multi-stakeholder collaboration, 9) legitimacy, and 10) evaluation and continuous quality improvement. CONCLUSION: We have developed a framework to guide the development and dissemination of CRCs. This ethical framework can provide necessary guidance for those generating CRCs and may help them avoid a number of difficult issues associated with existing ones

Collaboration with general practitioners: preferences of medical specialists – a qualitative study

BACKGROUND: Collaboration between general practitioners (GPs) and specialists has been the focus of many collaborative care projects during the past decade. Unfortunately, quite a number of these projects failed. This raises the question of what motivates medical specialists to initiate and continue participating with GPs in new collaborative care models. The following question is addressed in this study: What motivates medical specialists to initiate and sustain new models for collaborating with GPs? METHODS: We conducted semi-structured interviews with eighteen medical specialists in the province of Groningen, in the North of The Netherlands. The sampling criteria were age, gender, type of hospital in which they were practicing, and specialty. The interviews were recorded, fully transcribed, and analysed by three researchers working independently. The resulting motivational factors were grouped into categories. RESULTS: 'Teaching GPs' and 'regulating patient flow' (referrals) appeared to dominate when the motivational factors were considered. In addition, specialists want to develop relationships with the GPs on a more personal level. Most specialists believe that there is not much they can learn from GPs. 'Lack of time', 'no financial compensation', and 'no support from colleagues' were considered to be the main concerns to establishing collaborative care practices. Additionally, projects were often experienced as too complex and time consuming whereas guidelines were experienced as too restrictive. CONCLUSION: Specialists are particularly interested in collaborating because the GP is the gatekeeper for access to secondary health care resources. Specialists feel that they are able to teach the GPs something, but they do not feel that they have anything to learn from the GPs. With respect to professional expertise, therefore, specialists do not consider GPs as equals. Once personal relationships with the GPs have been established, an informal network with incidental professional contact seems to be sufficient to satisfy the collaborative needs of the specialist. The concerns seem to outweigh any positive motivational forces to developing new models of collaborative practice

Increasing the satisfaction of general practitioners with continuing medical education programs: A method for quality improvement through increasing teacher-learner interaction

BACKGROUND: Continuing medical education (CME) for general practitioners relies on specialist-based teaching methods in many settings. Formal lectures by specialists may not meet the learning needs of practitioners and may cause dissatisfaction with traditional CME. Increasing learner involvement in teaching programs may improve learner satisfaction. METHODS: A quality improvement program for CME for 18 general practitioners in the Tel Aviv region was designed as a result of dissatisfaction with traditional CME activities. A two-step strategy for change was developed. The CME participants first selected the study topics relevant to them from a needs assessment and prepared background material on the topics. In the second step, specialist teachers were invited to answer questions arising from the preparation of selected topics. Satisfaction with the traditional lecture program and the new participatory program were assessed by a questionnaire. The quality criteria included the relevance, importance and applicability of the CME topic chosen to the participant's practice, the clarity of the presentation and the effective use of teaching aids by the lecturer and the potential of the lecturer to serve as a consultant to the participant. RESULTS: The participatory model of CME significantly increased satisfaction with relevance, applicability and interest in CME topics compared to the traditional lecture format. CONCLUSIONS: Increased learner participation in the selection and preparation of CME topics, and increased interaction between CME teachers and learners results in increased satisfaction with teaching programs. Future study of the effect of this model on physician performance is required

Development and validation of the Cambridge Multimorbidity Score

BACKGROUND: Health services have failed to respond to the pressures of multimorbidity. Improved measures of multimorbidity are needed for conducting research, planning services and allocating resources. METHODS: We modelled the association between 37 morbidities and 3 key outcomes (primary care consultations, unplanned hospital admission, death) at 1 and 5 years. We extracted development (n = 300 000) and validation (n = 150 000) samples from the UK Clinical Practice Research Datalink. We constructed a general-outcome multimorbidity score by averaging the standardized weights of the separate outcome scores. We compared performance with the Charlson Comorbidity Index. RESULTS: Models that included all 37 conditions were acceptable predictors of general practitioner consultations (C-index 0.732, 95% confidence interval [CI] 0.731-0.734), unplanned hospital admission (C-index 0.742, 95% CI 0.737-0.747) and death at 1 year (C-index 0.912, 95% CI 0.905-0.918). Models reduced to the 20 conditions with the greatest combined prevalence/weight showed similar predictive ability (C-indices 0.727, 95% CI 0.725-0.728; 0.738, 95% CI 0.732-0.743; and 0.910, 95% CI 0.904-0.917, respectively). They also predicted 5-year outcomes similarly for consultations and death (C-indices 0.735, 95% CI 0.734-0.736, and 0.889, 95% CI 0.885-0.892, respectively) but performed less well for admissions (C-index 0.708, 95% CI 0.705-0.712). The performance of the general-outcome score was similar to that of the outcome-specific models. These models performed significantly better than those based on the Charlson Comorbidity Index for consultations (C-index 0.691, 95% CI 0.690-0.693) and admissions (C-index 0.703, 95% CI 0.697-0.709) and similarly for mortality (C-index 0.907, 95% CI 0.900-0.914). INTERPRETATION: The Cambridge Multimorbidity Score is robust and can be either tailored or not tailored to specific health outcomes. It will be valuable to those planning clinical services, policymakers allocating resources and researchers seeking to account for the effect of multimorbidity