Darcey D. Terris

Patient preferences for psoriasis treatments: impact of treatment experience.

Background  Patient preferences for psoriasis treatments can impact treatment satisfaction and adherence and may therefore influence clinical outcome.

Cardiovascular and metabolic risk profile in German patients with moderate and severe psoriasis: a case control study

Patients with psoriasis have a higher risk of cardiovascular and metabolic comorbidities, attributable to lifestyle factors, but also to shared inflammatory pathways and genetic factors. To investigate the association between moderate and severe psoriasis and metabolic and cardiovascular comorbidities, 100 patients hospitalized at University Medical Centre Mannheim, Germany, for psoriasis treatment were compared to two age- and sex-matched control groups, the first comprising other hospitalized patients (HCG) and the second comprising healthy individuals from an industrial cohort study (ICG). Multivariate logistic regression analysis with stepwise inclusion of cardiovascular risk factors was performed. Patients with psoriasis had significantly increased prevalences of smoking, obesity, diabetes, insulin resistance, pro-atherogenic cholesterol profiles and myocardial infarction and significantly decreased cardioprotective adiponectin. Unexpectedly, regression models controlling for confounding factors predicted significantly decreased OR for elevated total cholesterol in psoriasis cases (vs HCG: OR=0.50, p=0.045; vs ICG: OR=0.26, p=0.006). In contrast, OR for pro-atherogenic cholesterol profiles with LDL/HDL >3 was markedly increased (OR=2.45, p=0.012 or OR=3.02, p=0.020). Moreover, participants with psoriasis had significantly increased OR for elevated CRP as compared to the ICG (5.25, p=0.001). Our findings underscore the importance of cardiovascular and metabolic risk screening for all patients with moderate and severe psoriasis, including young patients.

Matching physicians' treatment recommendations to patients' treatment preferences is associated with improvement in treatment satisfaction.

Background  Dissatisfaction with treatment is common among those with psoriasis. While incorporating patients’ preferences into the process of treatment decision‐making may improve satisfaction, this relationship has not been clearly established.

Toward more sustainable health care quality improvement in developing countries: the "little steps" approach.

Background Resource constraints are often identified as a hurdle to the sustainability of large-scale (national and regional) health care quality improvement (QI) programs in developing countries. However, poor fit of a QI model with a given countrys context may present the greater challenge. Methods To explore contextual factors influencing the sustainability of large-scale QI initiatives in developing countries, we performed a systematic literature review. Results Large-scale initiatives appear to have received significant attention only recently in these settings, as priority was traditionally given to extending service coverage. Further, these initiatives often relied on QI models originating from developed country settings, which differed significantly from the systems, resource structures, culture, and values found in the target country. The QI programs frequently focused on high-impact/immediate change rather than on program sustainability. Barriers to sustainability were identified during the planning, start-up, and continuation phases. On the basis of our review, greater attention to sustainable methods for large-scale QI in developing countries is needed. Conclusion We suggest a “Little Steps” approach that begins by defining QI concepts, goals, and processes in a manner congruent with the target setting and that builds upon existing systems, structures, and values. Despite immediate short-term needs, an approach emphasizing incremental QI achievements may be more effective in yielding sustainable improvements in health care quality at the national or regional level.

Data quality bias: an underrecognized source of misclassification in pay-for-performance reporting?

Pay-for-performance (P4P) initiatives, in which provider reimbursement is linked to quality assessment, are receiving increasing attention as a possible approach to encouraging and accelerating quality improvement in Americas health care systems. The potential of P4P programs, however, is constrained by the quality of data and information resources available for performance reporting. Accurate and reliable appraisal of health care quality is a challenging issue, as achieving recommended processes of care and desired health outcomes is influenced by a diverse range of interrelated factors occurring at multiple levels and arising from multiple sources within the patient encounter, health care system, and larger environment. The challenge of quality assessment is further complicated by the variable quality of data available for reporting by each provider. When data quality varies systematically among providers, a significant risk of inequity in assessment, and therefore reimbursement under P4P programs, may occur. The issue of data quality should be investigated and addressed before widespread implementation of P4P programs is pursued. Significant investment in data collection and reporting mechanisms may be required, especially in resource-limited settings, to achieve the intended effects and avoid increasing disparities in health care quality.

The one-person randomized controlled trial.

Currently, the gold standard for collection of clinical evidence is the randomized controlled trial (RCT), preferably with large, multicenter samples of subjects. Although this approach provides valuable information, many clinicians find it difficult to translate RCT results to the individual patient level. In this report, a statistical approach called Design of Experiments (DOE) is described as a method of applying the principles of RCTs one person at a time. An overview of the method, with a simple clinical example, is presented. As shown, DOE is a more efficient method than the sequential approach often taken by clinicians and their patients when evaluating various treatment choices. Further, the effect of multiple interventions can be assessed, alone or in combination with each other. In this way, DOE can be an important addition to the field of evidence-based medicine, although further studies are needed.

Organizational Coherence in Health Care Organizations: Conceptual Guidance to Facilitate Quality Improvement and Organizational Change

Objective: We sought to improve our understanding of how health care quality improvement (QI) methods and innovations could be efficiently and effectively translated between settings to reduce persistent gaps in health care quality both within and across countries. We aimed to examine whether we could identify a core set of organizational cultural attributes, independent of context and setting, which might be associated with success in implementing and sustaining QI systems in health care organizations. Methods: We convened an international group of investigators to explore the issues of organizational culture and QI in different health care contexts and settings. This group met in person 3 times and held a series of conference calls to discuss emerging ideas over 2 years. Investigators also conducted pilot studies in their home countries to examine the applicability of our conceptual model. Results and Conclusions: We suggest that organizational coherence may be a critical element of QI efforts in health care organizations and propose that there are 3 key components of organizational coherence: (1) people, (2) processes, and (3) perspectives. Our work suggests that the concept of organizational coherence embraces both culture and context and can thus help guide both researchers and practitioners in efforts to enhance health care QI efforts, regardless of organizational type, location, or context.

It is not always about gains: utilities and disutilities associated with treatment features in patients with moderate-to-severe psoriasis

Background Patient-centered care has been proposed as a strategy for improving treatment outcomes in the management of psoriasis and other chronic diseases. A more detailed understanding of patients’ utilities and disutilities associated with treatment features may facilitate shared decision-making in the clinical encounter. The purpose of this study was to examine the features of psoriasis treatment that are most and least preferred by patients and to identify correlates of these preferences. Methods A cross-sectional survey of 163 patients with moderate-to-severe psoriasis was conducted in a German academic medical center. We assessed patients’ characteristics, elicited their preferences for a range of potential treatment features, and quantified preference scores (utilities) associated with each treatment feature using hierarchical Bayes estimation. After identifying the most and least preferred treatment features, we explored correlates of these preferences using multivariate regression models. Results Mean preference scores (MPS) for the least preferred treatment features were consistently greater than those for the most preferred treatment features. Patients generally expressed strong preferences against prolonged treatments in the inpatient setting (MPS = −13.48) and those with a lower probability of benefit (MPS = −12.28), while treatments with a high probability of benefit (MPS = 10.51) were generally preferred. Younger patients and women were more concerned with treatment benefit as compared with older patients and men. Conclusion Both negative and positive preferences appear important for shared decision-making. Recognition of characteristics associated with strong negative preferences may be particularly useful in promoting patient-centered environments.

Exploring the potential of a multi-level approach to improve capability for continuous organizational improvement and learning in a Swedish healthcare region

BackgroundEldercare and care of people with functional impairments is organized by the municipalities in Sweden. Improving care in these areas is complex, with multiple stakeholders and organizations. Appropriate strategies to develop capability for continuing organizational improvement and learning (COIL) are needed. The purpose of our study was to develop and pilot-test a flexible, multilevel approach for COIL capability building and to identify what it takes to achieve changes in key actors’ approaches to COIL. The approach, named “Sustainable Improvement and Development through Strategic and Systematic Approaches” (SIDSSA), was applied through an action-research and action-learning intervention.MethodsThe SIDSSA approach was tested in a regional research and development (R&D) unit, and in two municipalities handling care of the elderly and people with functional impairments. Our approach included a multilevel strategy, development loops of five flexible phases, and an action-learning loop. The approach was designed to support systems understanding, strategic focus, methodological practices, and change process knowledge - all of which required double-loop learning. Multiple qualitative methods, i.e., repeated interviews, process diaries, and documents, provided data for conventional content analyses.ResultsThe new approach was successfully tested on all cases and adopted and sustained by the R&D unit. Participants reported new insights and skills. The development loop facilitated a sense of coherence and control during uncertainty, improved planning and problem analysis, enhanced mapping of context and conditions, and supported problem-solving at both the individual and unit levels. The systems-level view and structured approach helped participants to explain, motivate, and implement change initiatives, especially after working more systematically with mapping, analyses, and goal setting.ConclusionsAn easily understood and generalizable model internalized by key organizational actors is an important step before more complex development models can be implemented. SIDSSA facilitated individual and group learning through action-learning and supported systems-level views and structured approaches across multiple organizational levels. Active involvement of diverse organizational functions and levels in the learning process was facilitated. However, the time frame was too short to fully test all aspects of the approach, specifically in reaching beyond the involved managers to front-line staff and patients.