Paul Bartels

Validity and underrecording of diagnosis of COPD in the Danish National Patient Registry.

INTRODUCTION We examined the positive predictive value of diagnoses of acute exacerbation of chronic obstructive pulmonary disease (COPD) in the Danish National Patient Registry. We also examined the negative predictive value of acute pneumonia or respiratory failure discharge diagnoses for absence of underlying COPD. METHODS We identified all patients aged 30 years or older with acute hospital admission in Denmark from January 1st to December 31st 2008. Physicians at 34 Danish hospitals retrieved and reviewed medical records for 1581 patients with a discharge diagnosis of COPD, and for 1546 patients with a discharge diagnosis of either pneumonia or respiratory failure but no COPD diagnosis. Presence of COPD was assessed based on medical history, clinical symptoms and findings, and spirometry results. RESULTS The overall positive predictive value for COPD was 92% (95% confidence interval [CI] = 91-93%). Among patients coded with pneumonia or respiratory failure but not COPD, 19% (95% CI = 17-21%) had COPD, corresponding to a negative predictive value for COPD of 81% (95% CI = 79-83%). CONCLUSIONS The positive predictive value of acute COPD discharge diagnoses in the Danish National Patient Registry is high. At the same time, there is a substantial underrecording of COPD during hospitalizations with other acute respiratory disorders like pneumonia and respiratory failure.

Deepening our understanding of quality improvement in Europe (DUQuE): overview of a study of hospital quality management in seven countries

Introduction and Objective This paper provides an overview of the DUQuE (Deepening our Understanding of Quality Improvement in Europe) project, the first study across multiple countries of the European Union (EU) to assess relationships between quality management and patient outcomes at EU level. The paper describes the conceptual framework and methods applied, highlighting the novel features of this study. Design DUQuE was designed as a multi-level cross-sectional study with data collection at hospital, pathway, professional and patient level in eight countries. Setting and Participants We aimed to collect data for the assessment of hospital-wide constructs from up to 30 randomly selected hospitals in each country, and additional data at pathway and patient level in 12 of these 30. Main outcome measures A comprehensive conceptual framework was developed to account for the multiple levels that influence hospital performance and patient outcomes. We assessed hospital-specific constructs (organizational culture and professional involvement), clinical pathway constructs (the organization of care processes for acute myocardial infarction, stroke, hip fracture and deliveries), patient-specific processes and outcomes (clinical effectiveness, patient safety and patient experience) and external constructs that could modify hospital quality (external assessment and perceived external pressure). Results Data was gathered from 188 hospitals in 7 participating countries. The overall participation and response rate were between 75% and 100% for the assessed measures. Conclusions This is the first study assessing relation between quality management and patient outcomes at EU level. The study involved a large number of respondents and achieved high response rates. This work will serve to develop guidance in how to assess quality management and makes recommendations on the best ways to improve quality in healthcare for hospital stakeholders, payers, researchers, and policy makers throughout the EU.

Socioeconomic Differences in Quality of Care and Clinical Outcome After Stroke A Nationwide Population-Based Study

Background and Purpose— The association among socioeconomic status, quality of care, and clinical outcome after stroke remains poorly understood. In a Danish nationwide follow-up study, we examined whether socioeconomic-related differences in acute stroke care occur and, if so, whether they explain socioeconomic differences in case-fatality and readmission risk. Methods— Using population-based public registries, we identified and followed all patients aged ⩽65 years admitted with stroke from 2003 to 2007 (n=14 545). We compared the proportion of patients receiving 7 specific processes of care according to income, educational attainment, and employment status. Furthermore, we computed 30-day and 1-year hazard ratios for death and readmission adjusted for patient characteristics and received processes of acute stroke care. Results— For low-income patients and disability pensioners, the relative risk of receiving all of the relevant processes of care was 0.82 (95% CI, 0.78 to 0.86) and 0.83 (95% CI, 0.79 to 0.87), respectively, compared with high-income patients and employed patients. Adjusted 30-day and 1-year hazard ratios for death for unemployed patients were 1.57 (95% CI, 1.25 to 1.97) and 1.58 (1.32 to 1.88), respectively, compared with employed patients. Unemployed patients also had a higher risk of readmission. The differences in mortality and readmission risk remained after controlling for received processes of acute stroke care. Conclusions— Low socioeconomic status was associated with a lower chance of receiving optimal acute stroke care. However, the differences in acute care did not appear to explain socioeconomic differences in mortality and readmission risk.

Quality of Care and Mortality Among Patients With Stroke: A Nationwide Follow-up Study

Background:The relationship between process and outcome measures among patients with stroke is unclear. Objectives:To examine the association between quality of care and mortality among patients with stroke in a nationwide population-based follow-up study. Methods:Using data from The Danish National Indicator Project, a quality improvement initiative with participation of all Danish hospital departments caring for patients with stroke, we identified 29,573 patients hospitalized with stroke between January 13, 2003 and October 31, 2005. Quality of care was measured in terms of 7 specific criteria: early admission to a stroke unit, early initiation of antiplatelet or oral anticoagulant therapy, early examination with computed tomography/magnetic resonance imaging scan, and early assessment by a physiotherapist, an occupational therapist, and of nutritional risk. Data on 30- and 90-day mortality rates were obtained through the Danish Civil Registration System. Results:Six of 7 of these criteria were associated with lower 30- and 90-day mortality rates. Adjusted mortality rate ratios corrected for clustering by department ranged from 0.41 to 0.83. We found indication of an inverse dose-response relationship between the number of quality of care criteria met and mortality; the lowest mortality rate was found among patients whose care met all criteria compared with patients whose care failed to meet any criteria (ie, adjusted 30-day mortality rate ratios: 0.45, 95% confidence interval: 0.24–0.66). When analyses were stratified by age and sex, the dose-response relationship was found in all subgroups. Conclusions:Higher quality of care during the early phase of stroke was associated with substantially lower mortality rates.

Sex-Related Differences in Quality of Care and Short-Term Mortality Among Patients With Acute Stroke in Denmark: A Nationwide Follow-Up Study

Background and Purpose— Sex may predict level of care and successive outcome among patients with stroke. We examined fulfillment of quality of care criteria according to sex and possible impact of any sex-related differences on short-term mortality in a population-based nationwide follow-up study in Denmark. Methods— We identified 29 549 patients admitted with stroke between January 2003 and October 2005 in the Danish National Indicator Project. Data on 30- and 90-day mortality were obtained from The Civil Registration System. We compared proportions of patients receiving adequate care between sexes, as measured by admission to a specialized stroke unit, administration of antiplatelet or anticoagulant therapy, examination with CT/MRI scan, and assessment by a physiotherapist, an occupational therapist, and of nutritional risk. Further, we computed 30- and 90-day mortality rate ratios (MRR), adjusted for patient characteristics, fulfillment of quality of care criteria, and department. Results— The proportion of patients who received adequate care was either slightly lower or similar among women when compared to men. The relative risks (RR) of receiving specific components of care ranged from 0.84 (95% confidence interval [CI]:0.74 to 0.96) to 1.01 (95% CI:0.96 to 1.06) when comparing sexes. The adjusted mortality rate ratios were lower among women and adjustment for fulfillment of quality of care criteria had only marginal impact. Conclusions— There appear not to be any substantial sex-related differences in acute hospital care among patients with stroke in Denmark. The lower female short-term mortality is therefore most likely explained by other factors.

Quality of care and 30 day mortality among patients with hip fractures: a nationwide cohort study

BackgroundWe examined the association between quality of care and 30 day mortality in a nationwide cohort of patients hospitalized with hip fracture.MethodsWe used data from The Danish National Indicator Project, a quality improvement initiative with participation of more than 90% of Danish hospital departments caring for patients with hip fracture between August 16, 2005 and August 15, 2006. Quality of care was measured in terms of meeting five specific criteria: early assessment of the patients nutritional risk, systematic pain assessment during mobilization, assessment of Activities of Daily Living (ADL) before the fracture, assessment of ADL before discharge, and initiation of treatment to prevent future osteoporotic fractures. The association between meeting each of the quality of care criteria for the patient and 30 day mortality was examined using logistic regression to adjust for potential confounders.Results6,266 patients hospitalized with an incident episode of hip fracture were included in the study. For four of the five quality of care criteria, patients who met the criterion had substantially lower 30 day mortality after hip fracture. The adjusted mortality odds ratios (ORs) ranged from 0.42 (95% CI, 0.30 to 0.58) for assessment of ADL before discharge (excluding deaths during hospitalization) to 0.72 (95% CI, 0.52 to 1.00) for systematic pain assessment. We found an inverse dose-response relationship between the number of quality of care criteria met and 30 day mortality; the lowest mortality was found among patients for whom all five quality of care criteria were met, as compared with patients for whom no quality of care criteria were met: adjusted mortality OR 0.18 (95% CI, 0.09 to 0.36).ConclusionHigher quality of care during hospitalization with hip fracture was associated with lowered 30 day mortality.

Selection of indicators for continuous monitoring of patient safety: recommendations of the project 'safety improvement for patients in Europe'

BACKGROUND Initiatives to improve patient safety have high priority among health professionals and politicians in most developed countries. Currently, however, assessment of patient safety problems relies mainly on case-based methodologies. The evidence for their efficiency and reproducibility, proving that safety of care has improved with their usage, is questionable. The exact incidence and prevalence of patient safety quality problems are unknown. Therefore, there is a need for firm, evidence-based methods to survey and develop patient safety and derived activities. OBJECTIVE The objective of this paper is to describe a method to select patient safety indicators and present the indicators derived through this process. METHODS The patient safety indicators were derived and recommended for use in a formalized consensus process based on literature review, targeted information gathering, expert consultation and rating procedures. RESULTS A total of 42 indicators, of which 28 originated from existing international indicator programmes, were selected. The processes and outcome indicators that were recommended for institutional-level use in Europe were 24, covering safety of care aspects such as culture, infections, surgical complications, medication errors, obstetrics, falls and specific diagnostic areas. CONCLUSION The patient safety indicators recommended present a set of possible measures of patient safety. One of the future perspectives of implementing patient safety indicators for systematic monitoring is that it will be possible to continuously estimate the prevalence and incidence of patient safety quality problems. The lesson learnt from quality improvement is that it will pay off in terms of improving patient safety.

Evidence-based organization and patient safety strategies in European hospitals.

Objective To explore how European hospitals have implemented patient safety strategies (PSS) and evidence-based organization of care pathway (EBOP) recommendations and examine the extent to which implementation varies between countries and hospitals. Design Mixed-method multilevel cross-sectional design in seven countries as part of the European Union-funded project ‘Deepening our Understanding of Quality improvement in Europe’ (DUQuE). Setting and participants Seventy-four acute care hospitals with 292 departments managing acute myocardial infarction (AMI), hip fracture, stroke, and obstetric deliveries. Main outcome measure Five multi-item composite measures—one generic measure for PSS and four pathway-specific measures for EBOP. Results Potassium chloride had only been removed from general medication stocks in 9.4–30.5% of different pathways wards and patients were adequately identified with wristband in 43.0–59.7%. Although 86.3% of areas treating AMI patients had immediate access to a specialist physician, only 56.0% had arrangements for patients to receive thrombolysis within 30 min of arrival at the hospital. A substantial amount of the total variance observed was due to between-hospital differences in the same country for PSS (65.9%). In EBOP, between-country differences play also an important role (10.1% in AMI to 57.1% in hip fracture). Conclusions There were substantial gaps between evidence and practice of PSS and EBOP in a sample of European hospitals and variations due to country differences are more important in EBOP than in PSS, but less important than within-country variations. Agencies supporting the implementation of PSS and EBOP should closely re-examine the effectiveness of their current strategies.

Quality improvement and accountability in the Danish health care system

Denmark has unique opportunities for quality measurement and benchmarking since Denmark has well-developed health registries and unique patient identifier that allow all registries to include patient-level data and combine data into sophisticated quality performance monitoring. Over decades, Denmark has developed and implemented national quality and patient safety initiatives in the healthcare system in terms of national clinical guidelines, performance and outcome measurement integrated in clinical databases for important diseases and clinical conditions, measurement of patient experiences, reporting of adverse events, national handling of patient complaints, national accreditation and public disclosure of all data on the quality of care. Over the years, Denmark has worked up a progressive and transparent just culture in quality management; the different actors at the different levels of the healthcare system are mutually attentive and responsive in a coordinated effort for quality of the healthcare services. At national, regional, local and hospital level, it is mandatory to participate in the quality initiatives and to use data and results for quality management, quality improvement, transparency in health care and accountability. To further develop the Danish governance model, it is important to expand the model to the primary care sector. Furthermore, a national quality health programme 2015-18 recently launched by the government supports a new development in health care focusing upon delivering high-quality health care-high quality is defined by results of value to the patients.

Quality management and perceptions of teamwork and safety climate in European hospitals

OBJECTIVE This study aimed to investigate the associations of quality management systems with teamwork and safety climate, and to describe and compare differences in perceptions of teamwork climate and safety climate among clinical leaders and frontline clinicians. METHOD We used a multi-method, cross-sectional approach to collect survey data of quality management systems and perceived teamwork and safety climate. Our data analyses included descriptive and multilevel regression methods. SETTING AND PARTICIPANTS Data on implementation of quality management system from seven European countries were evaluated including patient safety culture surveys from 3622 clinical leaders and 4903 frontline clinicians. MAIN OUTCOME MEASURES Perceived teamwork and safety climate. RESULTS Teamwork climate was reported as positive by 67% of clinical leaders and 43% of frontline clinicians. Safety climate was perceived as positive by 54% of clinical leaders and 32% of frontline clinicians. We found positive associations between implementation of quality management systems and teamwork and safety climate. CONCLUSIONS Our findings, which should be placed in a broader clinical quality improvement context, point to the importance of quality management systems as a supportive structural feature for promoting teamwork and safety climate. To gain a deeper understanding of this association, further qualitative and quantitative studies using longitudinally collected data are recommended. The study also confirms that more clinical leaders than frontline clinicians have a positive perception of teamwork and safety climate. Such differences should be accounted for in daily clinical practice and when tailoring initiatives to improve teamwork and safety climate.