scholarly journals The association between first-time accreditation and the delivery of recommended care: a before and after study in the Faroe Islands

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Maria Daniella Bergholt ◽  
Anne Mette Falstie-Jensen ◽  
Peter Hibbert ◽  
Barbara Joensen Eysturoy ◽  
Gunnvá Guttesen ◽  
...  
Keyword(s):  
Heart Failure ◽  
Gastric Ulcer ◽  
Hip Fracture ◽  
Transient Ischemic Attack ◽  
Recommended Care ◽  
Bleeding Gastric Ulcer ◽  
Before And After ◽  
Ischemic Attack ◽  
First Time ◽  
Before And After Study

Abstract Background Significant resources are spent on hospital accreditation worldwide. However, documentation of the effects of accreditation on processes, quality of care and outcomes in healthcare remain scarce. This study aimed to examine changes in the delivery of patient care in accordance with clinical guidelines (recommended care) after first-time accreditation in a care setting not previously exposed to systematic quality improvement initiatives. Methods We conducted a before and after study based on medical record reviews in connection with introducing first-time accreditation. We included patients with stroke/transient ischemic attack, bleeding gastric ulcer, diabetes, chronic obstructive pulmonary disease (COPD), childbirth, heart failure and hip fracture treated at public, non-psychiatric Faroese hospitals during 2012–2013 (before accreditation) or 2017–2018 (after accreditation). The intervention was the implementation of a modified second version of The Danish Healthcare Quality Program (DDKM) from 2014 to 2016 including an on-site accreditation survey in the Faroese hospitals. Recommended care was assessed using 63 disease specific patient level process performance measures in seven clinical conditions. We calculated the fulfillment and changes in the opportunity-based composite score and the all-or-none score. Results We included 867 patient pathways (536 before and 331 after). After accreditation, the total opportunity-based composite score was marginally higher though the change did not reach statistical significance (adjusted percentage point difference (%): 4.4%; 95% CI: − 0.7 to 9.6). At disease level, patients with stroke/transient ischemic attack, bleeding gastric ulcer, COPD and childbirth received a higher proportion of recommended care after accreditation. No difference was found for heart failure and diabetes. Hip fracture received less recommended care after accreditation. The total all-or-none score, which is the probability of a patient receiving all recommended care, was significantly higher after accreditation (adjusted relative risk (RR): 2.32; 95% CI: 2.03 to 2.67). The improvement was particularly strong for patients with COPD (RR: 16.22; 95% CI: 14.54 to 18.10). Conclusion Hospitals were in general more likely to provide recommended care after first-time accreditation.

Reflection on research methods: The before and after study.

2019 ◽  
Author(s):  
Mohammad Cheik-Hussein ◽  
Ian Harris ◽  
Adriane Lewin
Keyword(s):  
Hip Fracture ◽  
Study Design ◽  
Secular Trend ◽  
Population Level ◽  
Control Group ◽  
Fracture Failure ◽  
Before And After ◽  
Underlying Trend ◽  
Before And After Study ◽  
Actual Intervention

Abstract Background Before and after studies allow for the investigation of population-level health interventions and are a valuable study design in situations where randomisation is not feasible. The before and after study design involves measuring an outcome both before and after an intervention and comparing the outcome rates in both time periods to determine the effectiveness of the intervention. These studies do not involve a contemporaneous control group and must therefore take into account any underlying secular trends in order to separate the effect of the intervention from any pre-existing trend. Neglecting this important step can lead to spurious results.Methods To illustrate the importance of accounting for underlying trends, we performed a before and after study assessing 30-day mortality in hip fracture patients without any actual intervention, and instead designated an arbitrarily-chosen time-point as our ‘intervention’. We did this to ensure that we were basing our results exclusively on the underlying trend throughout the studied period and also to enable us to show that even an intervention of nothing may be spuriously interpreted to have an effect if the before and after study is incorrectly analysed. Results We found a secular trend in our data showing improving 30-day mortality in hip fracture patients in our institution. We then demonstrated that disregarding this underlying trend showed that our intervention of nothing ‘resulted’ in a significant decrease in mortality, from 6.7% in the ‘before’ period to 3.1% in the ‘after’ period (p<0.0008). This apparent impact on mortality disappeared when we accounted for the underlying trend in our analysis (IRR of 0.75, 95% CI 0.32 – 1.78; p=0.5). In the context of declining 30-day mortality following hip fracture, failure to consider the existing underlying trend lead us to believe that it was our ‘intervention’ that ‘caused’ the decrease in mortality in the ’after’ period compared to the ‘before’ period when our results clearly show that mortality was decreasing irrespective of any intervention.Conclusion Our study highlights the importance of appropriate measurement and consideration of underlying trends when analysing data from before and after studies and illustrates what can happen should researchers neglect this important step.

scholarly journals Development and Validation of a Risk Score Model for Predicting the Cardiovascular Outcomes After Breast Cancer Therapy: The CHEMO‐RADIAT Score

2021 ◽  
Author(s):  
Do Young Kim ◽  
Myung‐Soo Park ◽  
Jong‐Chan Youn ◽  
Sunki Lee ◽  
Jae Hyuk Choi ◽  
...  
Keyword(s):  
Risk Factors ◽  
Myocardial Infarction ◽  
Heart Failure ◽  
Cardiovascular Risk ◽  
Transient Ischemic Attack ◽  
Left Breast ◽  
Major Adverse Cardiovascular Events ◽  
Score Model ◽  
Ischemic Attack ◽  
Anthracycline Dose

Background Cardiovascular disease is an important cause of mortality among survivors of breast cancer (BC). We developed a prediction model for major adverse cardiovascular events after BC therapy, which is based on conventional and BC treatment‐related cardiovascular risk factors. Methods and Results The cohort of the study consisted of 1256 Asian female patients with BC from 4 medical centers in Korea and was randomized in a 1:1 ratio into the derivation and validation cohorts. The outcome measures comprised cardiovascular mortality, myocardial infarction, congestive heart failure, and transient ischemic attack/stroke. To correct overfitting, a penalized Cox proportional hazards regression was performed with a cross‐validation approach. Number of cardiovascular diseases (myocardial infarction, peripheral artery disease, heart failure, and transient ischemic attack/stroke), number of baseline cardiovascular risk factors (hypertension, age ≥60, body mass index ≥30 kg/m 2 , estimated glomerular filtration rate <60 mL/min per 1.73 m 2 , dyslipidemia, and diabetes mellitus), radiation to the left breast, and anthracycline dose per 100 mg/m 2 were included in the risk prediction model. The time‐dependent C‐indices at 3 and 7 years after BC diagnosis were 0.876 and 0.842, respectively, in the validation cohort. Conclusions A prediction score model, including BC treatment‐related risk factors and conventional risk factors, was developed and validated to predict major adverse cardiovascular events in patients with BC. The CHEMO‐RADIAT (congestive heart failure, hypertension, elderly, myocardial infarction/peripheral artery occlusive disease, obesity, renal failure, abnormal lipid profile, diabetes mellitus, irradiation of the left breast, anthracycline dose, and transient ischemic attack/stroke) score may provide overall cardiovascular risk stratification in survivors of BC and can assist physicians in multidisciplinary decision‐making regarding the BC treatment.

Abstract 4007: Association between Post-discharge Oral Antiplatelet Use and Clinical Outcomes among US Patients Hospitalized for Transient Ischemic Attack or Stroke

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Tanya Burton ◽  
Kathy Lang ◽  
Michael Lacey ◽  
Yanni Yu ◽  
Stephen Sander
Keyword(s):  
Clinical Outcomes ◽  
Transient Ischemic Attack ◽  
Significant Risk ◽  
Composite Endpoint ◽  
Gi Bleeding ◽  
Real World Data ◽  
Post Discharge ◽  
Vascular Events ◽  
Before And After ◽  
Ischemic Attack

Background: More than 800,000 Americans have a stroke or transient ischemic attack (TIA) each year. Antiplatelets are recommended to reduce the risk of recurrence and other clinical events. Conflicting data exist regarding the relative efficacy of two common oral antiplatelets (OAPs): aspirin plus extended-release dipyridamole (ASA-ERDP) and clopidogrel (CLO). Objective: To examine clinical outcomes using real-world data among patients hospitalized for TIA or stroke and initially prescribed ASA-ERDP or CLO post-discharge. Methods: This retrospective claims study from a US commercial and Medicare health plan analyzed adults who had at least one hospitalization for TIA or stroke between 01/2007 and 07/2009 and at least one pharmacy claim for an OAP within 30 days of discharge. Patients were observed for one year before and after the first hospitalization or until death. Post-discharge outcomes included vascular events, clinically relevant bleeds, and all-cause death. The composite and individual outcome measures were modeled using logistic multivariate (MV) regression, adjusting for baseline demographics, comorbidities, costs, and initial OAP use. Results: In total, 6,377 subjects (2,085 ASA-ERDP; 4,292 CLO) met the inclusion criteria. ASA-ERDP had a lower unadjusted proportion with the composite endpoint than CLO (19.1% vs. 22.0%, respectively; p=0.01). Significant unadjusted outcomes in the composite were: CHF (8.1% vs. 10.8%; p<0.001), MI (2.4% vs. 4.0%; p=0.001), GI bleeds (3.5% vs. 4.7%; p=0.03), and other hemorrhagic events (2.0% vs. 3.0%; p=0.02). Unadjusted stroke/TIA readmission was not significant (9.1% vs. 9.0%; p=0.95). MV modeling indicated age, comorbidities, index stroke/TIA event, and baseline costs as significant risk factors associated with the composite endpoint. Compared to CLO, the initial use of ASA-ERDP post-discharge was associated with 15% lower risk in the composite endpoint (OR = 0.85; p=0.03), but GI bleeding was the only significant individual component (OR=0.56; p=0.003). Conclusion: This study suggests that in the year following discharge for TIA or stroke, patients who received ASA-ERDP had a lower likelihood of the composite endpoint, due partly to GI bleeding, than patients who received CLO.

A Retrospective Study of Current Anticoagulant Use in Patients with Atrial Fibrillation: Results from a Managed Care Database.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 2246-2246
Author(s):  
Miranda Murray ◽  
Howard Friedman
Keyword(s):  
Risk Factors ◽  
Heart Failure ◽  
Atrial Fibrillation ◽  
Congestive Heart Failure ◽  
Managed Care ◽  
Anticoagulant Therapy ◽  
Transient Ischemic Attack ◽  
Clinical Care ◽  
Significant Risk ◽  
Ischemic Attack

Abstract The vitamin K antagonist warfarin is currently the mainstay of anticoagulant therapy for patients with atrial fibrillation (AF), in whom it has been shown to be effective in preventing stroke. However, it is underused because, despite the quality of clinical care, warfarin can be a difficult drug to manage well. When initiating therapy, patients may require several visits to a coagulation clinic to achieve an international normalized ratio (INR) within the safe and effective range (INR 2–3). Thereafter, frequent monitoring of patients receiving warfarin may still be required due to intrapatient variability. Despite the benefits, studies have shown that approximately 50% of patients who should receive warfarin are not prescribed it or do not receive it. This study was performed to investigate the use of warfarin in eligible patients with AF, for whom it was indicated. Using the US PharMetrics database from 51 managed care organizations, data entered between January 1997 and April 2004, from 5940 patients (>18 years of age with a diagnosis of AF [ICD 9] for whom warfarin was indicated), were analyzed. Patients were excluded if they were not in the database 30 days before and 120 days after their initial diagnosis of AF. Patients were divided into four distinct cohorts, based on treatment patterns: steady users (at least 3 months of warfarin use); discontinued users (used warfarin for only 3 months); non-users (warfarin use for <30 days); and intermittent users (used warfarin prior to first diagnosis of AF, or had less than two prescriptions). Analysis showed that only 31% (1854) of patients were steady users, whereas 59% (3521) of patients were non-users. Also, 4% (246) and 5% (319) of patients were discontinued users and intermittent users, respectively. In addition to a diagnosis of AF, many patients had significant risk factors for stroke: hypertension (48%); diabetes (23%); congestive heart failure (21%); age 75 or older (19%); history of stroke or transient ischemic attack (7%). However, the study showed that patients prescribed warfarin did not have more risk factors compared with long-term steady warfarin users and warfarin non-users (see table). Overall, this study shows that warfarin is underused, even in patients with significant risk factors for stroke, which highlights the need for new, simpler, oral anticoagulant therapy. Risk factors Total population [n (%)] Steady warfarin (%) Discontinued (%) Non-warfarin (%) Intermittent (%) NB Cumulative numbers of risk factors were constructed by assigning one point for each of the following: congestive heart failure; hypertension; age >75; diabetes; with two points added for prior stroke or transient ischemic attack 0 2036 (32) 32 29 36 34 1 1774 (30) 30 27 30 30 2 1197 (20) 22 23 19 23 3 623 (10) 11 13 10 8 4 204 (3) 3 4 4 4 5/6 106 (2) 2 3 1 1

scholarly journals Effect of COVID-19 on First-Time Acute Stroke and Transient Ischemic Attack Admission Rates and Prognosis in Denmark

Circulation ◽  
2020 ◽  
Vol 142 (12) ◽  
pp. 1227-1229 ◽  
Author(s):  
Jawad H. Butt ◽  
Emil L. Fosbøl ◽  
Lauge Østergaard ◽  
Adelina Yafasova ◽  
Charlotte Andersson ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Transient Ischemic Attack ◽  
Admission Rates ◽  
Ischemic Attack ◽  
First Time
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