Hub Wollersheim

Public reporting in health care: how do consumers use quality-of-care information? A systematic review.

Background:One of the underlying goals of public reporting is to encourage the consumer to select health care providers or health plans that offer comparatively better quality-of-care. Objective:To review the weight consumers give to quality-of-care information in the process of choice, to summarize the effect of presentation formats, and to examine the impact of quality information on consumers’ choice behavior. The evidence is organized in a theoretical consumer choice model. Data Sources:English language literature was searched in PubMed, the Cochrane Clinical Trial, and the EPOC Databases (January 1990–January 2008). Study Selection:Study selection was limited to randomized controlled trails, controlled before-after trials or interrupted time series. Included interventions focused on choice behavior of consumers in health care settings. Outcome measures referred to one of the steps in a consumer choice model. The quality of the study design was rated, and studies with low quality ratings were excluded. Results:All 14 included studies examine quality information, usually CAHPS, with respect to its impact on the consumers choice of health plans. Easy-to-read presentation formats and explanatory messages improve knowledge about and attitude towards the use of quality information; however, the weight given to quality information depends on other features, including free provider choice and costs. In real-world settings, having seen quality information is a strong determinant for choosing higher quality-rated health plans. Conclusions:This review contributes to an understanding of consumer choice behavior in health care settings. The small number of included studies limits the strength of our conclusions.

Organizational interventions to implement improvements in patient care: a structured review of reviews

BackgroundChanging the organization of patient care should contribute to improved patient outcomes as functioning of clinical teams and organizational structures are important enablers for improvement.ObjectiveTo provide an overview of the research evidence on effects of organizational strategies to implement improvements in patient care.DesignStructured review of published reviews of rigorous evaluations.Data sourcesPublished reviews of studies on organizational interventions.Review methodsSearches were conducted in two data-bases (Pubmed, Cochrane Library) and in selected journals. Reviews were included, if these were based on a systematic search, focused on rigorous evaluations of organizational changes, and were published between 1995 and 2003.Two investigators independently extracted information from the reviews regarding their clinical focus, methodological quality and main quantitative findings.ResultsA total of 36 reviews were included, but not all were high-quality reviews. The reviews were too heterogeneous for quantitative synthesis. None of the strategies produced consistent effects. Professional performance was generally improved by revision of professional roles and computer systems for knowledge management. Patient outcomes was generally improved by multidisciplinary teams, integrated care services, and computer systems. Cost savings were reported from integrated care services. The benefits of quality management remained uncertain.ConclusionThere is a growing evidence base of rigorous evaluations of organizational strategies, but the evidence underlying some strategies is limited and for no strategy can the effects be predicted with high certainty.

Improving patient handovers from hospital to primary care: a systematic review.

BACKGROUND Evidence shows that suboptimum handovers at hospital discharge lead to increased rehospitalizations and decreased quality of health care. PURPOSE To systematically review interventions that aim to improve patient discharge from hospital to primary care. DATA SOURCES PubMed, CINAHL, PsycInfo, the Cochrane Library, and EMBASE were searched for studies published between January 1990 and March 2011. STUDY SELECTION Randomized, controlled trials of interventions that aimed to improve handovers between hospital and primary care providers at hospital discharge. DATA EXTRACTION Two reviewers independently abstracted data on study objectives, setting and design, intervention characteristics, and outcomes. Studies were categorized according to methodological quality, sample size, intervention characteristics, outcome, statistical significance, and direction of effects. DATA SYNTHESIS Of the 36 included studies, 25 (69.4%) had statistically significant effects in favor of the intervention group and 34 (94.4%) described multicomponent interventions. Effective interventions included medication reconciliation; electronic tools to facilitate quick, clear, and structured summary generation; discharge planning; shared involvement in follow-up by hospital and community care providers; use of electronic discharge notifications; and Web-based access to discharge information for general practitioners. Statistically significant effects were mostly found in reducing hospital use (for example, rehospitalizations), improvement of continuity of care (for example, accurate discharge information), and improvement of patient status after discharge (for example, satisfaction). LIMITATIONS Heterogeneity of the interventions and study characteristics made meta-analysis impossible. Most studies had diffuse aims and poor descriptions of the specific intervention components. CONCLUSION Many interventions have positive effects on patient care. However, given the complexity of interventions and outcome measures, the literature does not permit firm conclusions about which interventions have these effects. PRIMARY FUNDING SOURCE The European Union, the Framework Programme of the European Commission.

Retinal vein occlusion: A form of venous thrombosis or a complication of atherosclerosis? A meta-analysis of thrombophilic factors

Previous studies have shown an increased risk of retinal vein occlusion (RVO) in patients with hypertension, hypercholesterolemia and diabetes mellitus. Literature on the association between thrombophilic factors and RVO consists of small studies and case reports. The objective was to determine the relationship between thrombophilic risk factors and RVO. Thrombophilic risk factors analyzed were hyperhomocysteinemia, MTHFR gene mutation, factor V Leiden mutation, protein C and S deficiency, antithrombin deficiency, prothrombin gene mutation, anticardiolipin antibodies and lupus anticoagulant. For all currently known thrombophilic risk factors odds ratios for RVO were calculated as estimates of relative risk. The odds ratios were 8.9 (95% CI 5.7 - 13.7) for hyperhomocysteinemia, 3.9 (95% CI 2.3 - 6.7) for anticardiolipin antibodies, 1.2 (95% CI 0.9 - 1.6) for MTHFR, 1.5 (95% CI 1.0 - 2.2) for factor V Leiden mutation and 1.6 (95% CI 0.8 - 3.2) for prothrombin gene mutation. In conclusion, regarding thrombophilic risk factors and RVO there is only evidence for an association with hyperhomocysteinemia and anticardiolipin antibodies, factors that are known as risk factors for venous thrombosis as well as for arterial vascular disease. The minor effect of factor V Leiden mutation and the protrombin gene mutation (risk factors for venous thrombosis only) suggests that atherosclerosis might be an important factor in the development of CRVO.

Effectiveness of opportunistic brief interventions for problem drinking in a general hospital setting: systematic review

Abstract Objective To determine the effectiveness of opportunistic brief interventions for problem drinking in a general hospital setting. Design Systematic review. Data sources Medline, PsychInfo, Cochrane Library, reference lists from identified studies and review articles, and contact with experts. Main outcome measure Change in alcohol consumption. Results Eight studies were retrieved. Most had methodological weaknesses. Only one study, with a relatively intensive intervention and a short follow up period, showed a significantly large reduction in alcohol consumption in the intervention group. Conclusions Evidence for the effectiveness of opportunistic brief interventions in a general hospital setting for problem drinkers is still inconclusive.

Effectiveness of Nonpharmacological Interventions in Delaying the Institutionalization of Patients with Dementia: A Meta‐Analysis

Contemporary healthcare policies are designed to shape the conditions that can help delay the institutionalization of patients with dementia. This can be done by developing support programs that minimize healthcare risks for the patients with dementia and their informal caregivers. Many support programs have been developed, and some of them are effective, but there has been no systematic review with a meta‐analysis of all types of nonpharmacological support programs with odds of institutionalization or time to institutionalization as an outcome measure. A systematic review with a meta‐analysis was therefore conducted to estimate the overall effectiveness of nonpharmacological support programs for caregivers and patients with dementia that are intended to delay institutionalization. Thirteen support programs with a total of 9,043 patients were included in the meta‐analyses. The estimated overall effectiveness suggests that these programs significantly decrease the odds of institutionalization (odds ratio (OR)=0.66, 95% confidence interval (CI)=0.43–0.99, P=.05) and significantly increase the time to institutionalization (standardized mean difference (SMD)=1.44, 95% CI=0.07–2.81, P=.04). A meta‐analysis of the best‐quality studies still showed a positive significant result for the odds of institutionalization (OR=0.60, 95% CI=0.43–0.85, P=.004), although the time to institutionalization was no longer significant (SMD=1.55, 95% CI=–0.35– 3.45, P=.11). The analysis of the intervention characteristics showed that actively involving caregivers in making choices about treatments distinguishes effective from ineffective support programs. Further investigation should be directed toward calculating the potential efficiency of these support programs by applying net‐benefit or cost‐effectiveness analysis.

The Impact of Nonphysician Clinicians Do They Improve the Quality and Cost-Effectiveness of Health Care Services?

Health care is changing rapidly. Unacceptable variations in service access and quality of health care and pressures to contain costs have led to the redefinition of professional roles. The roles of nonphysician clinicians (nurses, physician assistants, and pharmacists) have been extended to the medical domain. It is expected that such revision of roles will improve health care effectiveness and efficiency. The evidence suggests that nonphysician clinicians working as substitutes or supplements for physicians in defined areas of care can maintain and often improve the quality of care and outcomes for patients. The effect on health care costs is mixed, with savings dependent on the context of care and specific nature of role revision. The evidence base underpinning these conclusions is strongest for nurses with a marked paucity of research into pharmacists and physician assistants. More robust evaluative studies into role revision are needed, particularly with regard to economic impacts, before definitive conclusions can be drawn.

Inflammation in deep vein thrombosis and the development of post‐thrombotic syndrome: a prospective study

Summary.  Background: The aim of this study was to investigate whether inflammatory markers (interleukin‐6 [IL‐6] and C‐reactive protein [CRP]) in the acute phase of deep vein thrombosis (DVT) are associated with elevated venous outflow resistance (VOR), thrombosis score (TS), reflux and the development of clinical post‐thrombotic syndrome (PTS). Methods: In 110 patients with a first DVT, plasma concentrations of IL‐6 and CRP were determined on the day of admission. VOR, TS and reflux were measured 7 days, 1 and 3 months after diagnosis. After 1 year patients were evaluated for PTS using the Clinical, Etiologic, Anatomic and Pathophysiologic (CEAP) classification and Villalta scale. Results: Median levels of IL‐6 and CRP were 7 pg mL−1 and 21 mg L−1, respectively. After 3 months, VOR was elevated in 33 patients (30%), TS in 33 (30%) and reflux in 57 (52%). Incidence of PTS was 36.7% using CEAP ≥ 3 and 35.4% using Villalta‐scale ≥ 5. Elevated levels of IL‐6 and CRP were related to higher outcomes of VOR after 3 months [relative risks (RR) 2.4 (95% CI 1.5–3.9) and 1.4 (1.1–3.3), respectively] and for IL‐6 to TS [1.5 (1.1–2.1)]. For reflux no relation was found. After 90 days, elevated outcomes of VOR, TS and reflux were related to PTS after 1 year. The association of IL‐6 and CRP with PTS was weak using the CEAP classification with a RR of 1.2 (0.7–2.2) and 1.8 (0.9–3.3) and absent according to the Villalta scale 0.6 (0.2–1.4) and 1.2 (0.6–2.5), respectively. Conclusion: The results of this study suggest that inflammation might play a role in incomplete thrombus clearance, venous outflow obstruction and the development of PTS after 1 year.

The post-thrombotic syndrome: incidence and prognostic value of non-invasive venous examinations in a six-year follow-up study

The ability to predict severity of the post-thrombotic syndrome (PTS) early after acute deep-vein thrombosis (DVT) is limited. The aim of our study was to examine the incidence of PTS prospectively and to evaluate the predictive value of non-invasive venous examinations shortly after DVT for the development of PTS. In 93 patients with DVT thrombosis score (TS), reflux, venous outflow resistance (VOR) and calf muscle pump dysfunction (CMP) were examined prospectively. After one, two and six years patients were evaluated for PTS using the clinical scale of the CEAP-classification (PTS present > or = 3 on a scale from 0 to 6). Area under the curves (AUC) were used to evaluate the predictive value of the non-invasive examinations at one and three months after diagnosis of DVT for future PTS. The cumulative incidence of PTS increased from 49% (32/65) after one year to 55% (36/65) and 56% (27/48) after two and six years, whereas the incidence of patients with PTS class 4 progressed from 20% after two years to 33% after six years. The prognostic value to predict PTS was highest for the combination of TS, VOR and reflux measured three months after diagnosis and showed an AUC of 0.77 (0.65-0.90) for PTS after one year. In conclusion, the incidence of PTS after DVT did not increase significantly after one year, whereas during longer follow-up the severity of PTS rose in patients with PTS. Moreover, measurement of TS, VOR and reflux three months after DVT could predict, with reasonable accuracy, the risk of PTS after one year of follow-up.

How to promote healthy behaviours in patients? An overview of evidence for behaviour change techniques

To identify the evidence for the effectiveness of behaviour change techniques, when used by health-care professionals, in accomplishing health-promoting behaviours in patients. Reviews were used to extract data at a study level. A taxonomy was used to classify behaviour change techniques. We included 23 systematic reviews: 14 on smoking cessation, 6 on physical exercise, and 2 on healthy diets and 1 on both exercise and diets. None of the behaviour change techniques demonstrated clear effects in a convincing majority of the studies in which they were evaluated. Techniques targeting knowledge (n = 210 studies) and facilitation of behaviour (n = 172) were evaluated most frequently. However, self-monitoring of behaviour (positive effects in 56% of the studies), risk communication (52%) and use of social support (50%) were most often identified as effective. Insufficient insight into appropriateness of technique choice and quality of technique delivery hinder precise conclusions. Relatively, however, self-monitoring of behaviour, risk communication and use of social support are most effective. Health professionals should avoid thinking that providing knowledge, materials and professional support will be sufficient for patients to accomplish change and consider alternative strategies which may be more effective.