Daan Aeyels

How do patients with uncontrolled diabetes in the Brussels-Capital Region seek and use information sources for their diet?

OBJECTIVE The aim of this study was to obtain qualitative data to understand how type 2 diabetic patients with unregulated blood glucose levels (HbA1c >140 mg/dL) seek and use information sources for their diet. METHODS A descriptive, explorative study design was used with focus group interviews in the Brussels-Capital Region. Each interview was recorded, transcribed literally, and analysed thematically using a grounded theory approach. RESULTS GPs were the most important information source in this study. GPs and other professionals were considered to be reliable sources of information by the patients. All patients received information passively at diagnosis. Patients that actively sought information differed in their search behaviour and reported they were not sufficiently informed. Some information sources remained unknown to the diabetic patients in this study. CONCLUSION Diabetic patients of the Brussels-Capital Region are not well informed about their diet. The main problem is how patients perceived the accessibility of information. Practice implications Public health strategies are required to promote well-informed, proactive patients supported by healthcare teams.

Lack of evidence and standardization in care pathway documents for patients with ST-elevated myocardial infarction:

Background: Clinical practice variation and the subsequent burden on health care quality has been documented for patients with ST-elevated myocardial infarction (STEMI). Reduction of clinical practice variation is possible by increasing guideline adherence. Care pathway documents can increase guideline adherence by implementing evidence-based key interventions and quality indicators in daily practice. Aims: This study aims to examine guideline adherence of care pathway documents for patients with STEMI. Methods: Lay-out, size and timeframe of submitted care pathways documents were analysed. Two independent reviewers used a checklist to systematically assess the guideline adherence of care pathway documents. The checklist comprised a set of key interventions and quality indicators extracted from evidence and international guidelines. The checklist distinguished the evidence level for each item and was validated by expert consensus. Results were verified by inviting participating hospitals to provide feedback. Results: Fifteen out of 25 invited hospitals submitted care pathway documents for STEMI. The care pathway documents differed in timeframe, lay-out and size. Analysis of the care pathway documents showed important variation in formalizing adherence to evidence: between hospitals, inclusion of 24 key interventions in care pathway documents varied from 13 to 97%. Inclusion of 11 essential quality indicators varied from 0 to 40%. Conclusion: Care pathway documents for patients with STEMI differ considerably in lay-out, timeframe and size. This study showed variation in, and suboptimal inclusion of, evidence-based key interventions and quality indicators in care pathway documents. The use of these care pathway documents might result in suboptimal quality of care for STEMI patients.

Key interventions and quality indicators for quality improvement of STEMI care: a RAND Delphi survey

Abstract Objective: Identification, selection and validation of key interventions and quality indicators for improvement of in hospital quality of care for ST-elevated myocardial infarction (STEMI) patients. Methods and Results: A structured literature review was followed by a RAND Delphi Survey. A purposively selected multidisciplinary expert panel of cardiologists, nurse managers and quality managers selected and validated key interventions and quality indicators prior for quality improvement for STEMI. First, 34 experts (76% response rate) individually assessed the appropriateness of items to quality improvement on a nine point Likert scale. Twenty-seven key interventions, 16 quality indicators at patient level and 27 quality indicators at STEMI care programme level were selected. Eighteen additional items were suggested. Experts received personal feedback, benchmarking their score with group results (response rate, mean, median and content validity index). Consequently, 32 experts (71% response rate) openly discussed items with an item-content validity index above 75%. By consensus, the expert panel validated a final set of 25 key interventions, 13 quality indicators at patient level and 20 quality indicators at care programme level prior for improvement of in hospital care for STEMI. Conclusions: A structured literature review and multidisciplinary expertise was combined to validate a set of key interventions and quality indicators prior for improvement of care for STEMI. The results allow researchers and hospital staff to evaluate and support quality improvement interventions in a large cohort within the context of a health care system.

Care Pathway Effect on In-Hospital Care for ST-Elevation Myocardial Infarction

Objectives: To study the care pathway effect on the percentage of patients with ST-elevation myocardial infarction (STEMI) receiving timely coronary reperfusion and the percentage of STEMI patients receiving optimal secondary prevention. Methods: A care pathway was implemented by the Collaborative Model for Achieving Breakthrough Improvement. One pre-intervention and 2 post-intervention audits included all adult STEMI patients admitted within 24 h after onset and eligible for reperfusion. Adjusted (hospital random intercepts and controls for transfer and out-of-office admission) differences in composite outcomes were analyzed by a multilevel logistic regression. Results: Significant improvements in intervals between the first medical contact (FMC) to percutaneous coronary intervention (PCI) and between the door to PCI were shown between post-intervention audit II and post-intervention audit I. Secondary prevention significantly deteriorated at post-intervention audit I but improved significantly between both post-intervention audits. Six out of nine outcomes were significantly poorer in the case of transfer. The interval from FMC to PCI was significantly poorer for patients admitted during out-of-office hours. Conclusions: After care pathway implementation, composite outcomes improved for in-hospital STEMI care. Collaborative efforts exploited heterogeneity in performance between hospitals. Iterative and incremental care pathway implementation maximized performance improvement.

Better hospital context increases success of care pathway implementation on achieving greater teamwork: a multicenter study on STEMI care

Objective To evaluate whether hospital context influences the effect of care pathway implementation on teamwork processes and output in STEMI care. Design A multicenter pre-post intervention study. Setting Eleven acute hospitals. Participants Cardiologists-in-chief, nurse managers, quality staff, quality managers and program managers reported on hospital context. Teamwork was rated by professional groups (medical doctors, nurses, allied health professionals, other) in the following departments: emergency room, catheterization lab, coronary care unit, cardiology ward and rehabilitation. Intervention Care pathway covering in-hospital care from emergency services to rehabilitation. Main outcome measures Hospital context was measured by the five dimensions of the Model for Understanding Success in Quality: microsystem, quality improvement team, quality improvement support, high-level organization, external environment. Teamwork process measures reflected teamwork between professional groups within departments and teamwork between departments. Teamwork output was measured through the level of organized care. Two-level regression analysis accounted for clustering of respondents within hospitals and assessed the influence of hospital context on the impact of care pathway implementation on teamwork. Results Care pathway implementation significantly improved teamwork processes both between professional groups (P < 0.001) and between departments (P < 0.001). Teamwork output also improved (P < 0.001). The effect of care pathway implementation on teamwork was more pronounced when the quality improvement team and quality improvement support and capacity were more positively reported on. Conclusions Hospitals can leverage the effect of quality improvement interventions such as care pathways by evaluating and improving aspects of hospital context.

Managing in-hospital quality improvement: An importance-performance analysis to set priorities for ST-elevation myocardial infarction care:

Background: A focus on specific priorities increases the success rate of quality improvement efforts for broad and complex-care processes. Importance-performance analysis presents a possible approach to set priorities around which to design and implement effective quality improvement initiatives. Persistent variation in hospital performance makes ST-elevation myocardial infarction care relevant to consider for importance-performance analysis. Aims: The purpose of this study was to identify quality improvement priorities in ST-elevation myocardial infarction care. Methods: Importance and performance levels of ST-elevation myocardial infarction key interventions were combined in an importance-performance analysis. Content validity indexes on 23 ST-elevation myocardial infarction key interventions of a multidisciplinary RAND Delphi Survey defined importance levels. Structured review of 300 patient records in 15 acute hospitals determined performance levels. The significance of between-hospital variation was determined by a Kruskal–Wallis test. A performance heat-map allowed for hospital-specific priority setting. Results: Seven key interventions were each rated as an overall improvement priority. Priority key interventions related to risk assessment, timely reperfusion by percutaneous coronary intervention and secondary prevention. Between-hospital performance varied significantly for the majority of key interventions. The type and number of priorities varied strongly across hospitals. Conclusions: Guideline adherence in ST-elevation myocardial infarction care is low and improvement priorities vary between hospitals. Importance-performance analysis helps clinicians and management in demarcation of the nature, number and order of improvement priorities. By offering a tailored improvement focus, this methodology makes improvement efforts more specific and achievable.