Prediction of acute appendicitis among patients with undifferentiated abdominal pain at emergency department

Background Early screening and accurately identifying Acute Appendicitis (AA) among patients with undifferentiated symptoms associated with appendicitis during their emergency visit will improve patient safety and health care quality. The aim of the study was to compare models that predict AA among patients with undifferentiated symptoms at emergency visits using both structured data and free-text data from a national survey. Methods We performed a secondary data analysis on the 2005-2017 United States National Hospital Ambulatory Medical Care Survey (NHAMCS) data to estimate the association between emergency department (ED) patients with the diagnosis of AA, and the demographic and clinical factors present at ED visits during a patient’s ED stay. We used binary logistic regression (LR) and random forest (RF) models incorporating natural language processing (NLP) to predict AA diagnosis among patients with undifferentiated symptoms. Results Among the 40,441 ED patients with assigned International Classification of Diseases (ICD) codes of AA and appendicitis-related symptoms between 2005 and 2017, 655 adults (2.3%) and 256 children (2.2%) had AA. For the LR model identifying AA diagnosis among adult ED patients, the c-statistic was 0.72 (95% CI: 0.69–0.75) for structured variables only, 0.72 (95% CI: 0.69–0.75) for unstructured variables only, and 0.78 (95% CI: 0.76–0.80) when including both structured and unstructured variables. For the LR model identifying AA diagnosis among pediatric ED patients, the c-statistic was 0.84 (95% CI: 0.79–0.89) for including structured variables only, 0.78 (95% CI: 0.72–0.84) for unstructured variables, and 0.87 (95% CI: 0.83–0.91) when including both structured and unstructured variables. The RF method showed similar c-statistic to the corresponding LR model. Conclusions We developed predictive models that can predict the AA diagnosis for adult and pediatric ED patients, and the predictive accuracy was improved with the inclusion of NLP elements and approaches.

The influence of primary care quality on nursing home admissions in a multimorbid population with and without dementia in Germany: a retrospective cohort study using health insurance claims data

Background Multimorbidity poses a challenge for high quality primary care provision for nursing care-dependent people with (PWD) and without (PWOD) dementia. Evidence on the association of primary care quality of multimorbid PWD and PWOD with the event of a nursing home admission (NHA) is missing. This study aimed to investigate the contribution of individual quality of primary care for chronic diseases in multimorbid care-dependent PWD and PWOD on the duration of ongoing residence at home before the occurrence of NHA. Methods We conducted a retrospective cohort study among elderly care-dependent PWD and PWOD in Germany for six combinations of chronic diseases using statutory health insurance claims data (2007–2016). Primary care quality was measured by 21 process and outcome indicators for hypertension, diabetes, depression, chronic obstructive pulmonary disease and heart failure. The primary outcome was time to NHA after initial onset of care-dependency. Multivariable Cox proportional hazard models were used to compare the time-to-event between PWD and PWOD. Results Among 5876 PWD and 12,837 PWOD 5130 NHA occurred. With the highest proportion of NHA for PWD with hypertension and depression and for PWOD with hypertension, diabetes and depression. Average duration until NHA ranged from 6.5 to 8.9 quarters for PWD and from 9.6 to 13.5 quarters for PWOD. Adjusted analyses show consistent associations of the quality of diabetes care with the duration of remaining in one’s own home regardless of the presence of dementia. Process indicators assessing guideline-fidelity are associated with remaining in one’s home longer, while indicators assessing complications, such as emergency inpatient treatment (HR = 2.67, 95% CI 1.99–3.60 PWD; HR = 2.81, 95% CI 2.28–3.47 PWOD) or lower-limb amputation (HR = 3.10, 95% CI 1.78–5.55 PWD; HR = 2.81, 95% CI 1.94–4.08 PWOD) in PWD and PWOD with hypertension and diabetes, increase the risk of NHA. Conclusions The quality of primary care provided to care-dependent multimorbid PWD and POWD, influences the time individuals spend living in their own homes after onset of care-dependency before a NHA. Health care professionals should consider possibilities and barriers of guideline-based, coordinated care for multimorbid care-dependent people. Further research on quality indicator sets that acknowledge the complexity of care for multimorbid elderly populations is needed.

Training interprofessional faculty in humanism and professionalism: a qualitative analysis of what is most important

Introduction: The capacity of healthcare professionals to work collaboratively influences faculty and trainees’ professional identity formation, well-being, and care quality. Part of a multi-institutional project*, we created the Faculty Fellowship for Leaders in Humanistic Interprofessional Education at Boston Children’s Hospital/ Harvard Medical School. We aimed to foster trusting relationships, reflective abilities, collaboration skills, and work together to promote humanistic values within learning environments. Objective: To examine the impact of the faculty fellowship from participants’ reports of “the most important thing learned”. Methods: We studied participants’ reflections after each of 16 1½ hour fellowship sessions. Curriculum content included: highly functioning teams, advanced team formation, diversity/inclusion, values, wellbeing/renewal/burnout, appreciative inquiry, narrative reflection, and others. Responses to “What was the most important thing you learned?” were analyzed qualitatively using a positivistic deductive approach. Results: Participants completed 136 reflections over 16 sessions–77% response rate (136/176). Cohort was 91% female; mean age 52.6 (range 32-65); mean years since completion of highest degree 21.4; 64% held doctorates, 36% master’s degrees. 46% were physicians, 27% nurses, 18% social workers, 9% psychologists. 27% participated previously in a learning experience focusing on interprofessional education, collaboration or practice. Most important learning included: Relational capacities/ Use of self in relationships 96/131 (73%); Attention to values 46/131 (35%); Reflection/ Self-awareness 44/131 (34%); Fostering humanistic learning environments 21/131 (16%). Discussion: Results revealed the importance of enhancing relational capacities and use of self in relationships including handling emotions; attention to values; reflection/self-awareness and recognition of assumptions; and fostering humanistic learning environments. These topics should receive more emphasis in interprofessional faculty development programs and may help identify teaching priorities. *Supported in part by a multi-institutional grant from the Josiah Macy, Jr. Foundation (Dr. Branch as PI; Dr. Rider as site PI).

What Does a Systems Approach to Quality Improvement Look Like in Practice?

Universally improving healthcare systems is difficult to achieve in practice with organisations implementing a range of quality improvement (QI) approaches, in varying and changing contexts, and efforts ranging from project-based improvements to whole system change. This study aimed to identify how organisations overcome the challenges to improving the quality of the services they deliver. Drawing on the eight challenges from the ‘Quality and Safety in Europe by Research (QUASER) hospital guide, we assessed eight cases reported by the UK-based regulator Care Quality Commission as improving their performance. A thematic analysis of these secondary data established that all eight challenges had been addressed or considered in varying degrees. Education and physical and technological challenges seemed less prominent than developments made to address other challenges such as developing leadership, structure, and culture to support improving quality. This paper relies on the analysis of secondary case data and one framework to assess improvement efforts. Further research is required to consider other models and frameworks and to collate longitudinal data to capture the dynamics and increasing the maturity of improving healthcare systems in practice.

Does the perceived healthcare quality provided by full-time government employee doctors in the public system differ from the perceived care quality in their own privately managed facilities in Nigeria?

Objective: Although the differences in the quality levels between the public and private sectors have been identified in literature not much is known about the level of quality differences that exist when full time government employee doctors offer the same clinical services in their own privately managed facilities. The objective of this study was to compare service user perceived quality of care provided by full-time government employee doctors in the public system and in their own privately managed facilities in Nigeria.Methods: A cross-sectional multistage sampling design was used to elicit service user views on process, structure and outcome elements of quality identified in the Donabedian’s care quality model. The software for population surveys in EPI Info 7 was used to calculate the required sample. A total of 407 questionnaires were administered and completed after a pre-test.Results: Respondents reported better health outcomes in private practice than in the public system and a majority would recommend visiting a dual physician’s private practice than the public system where they work full-time. Process aspects of quality, including better rapport with doctors, greater perceived confidentiality, shorter wait times, and absence of bureaucratic impediments were said to be better in privately managed facilities of government doctors. However, respondents said that the public sector was superior in respect of the structure element of quality as reflected in better infrastructure, equipment, and availability of drugs.Conclusions: Despite the relatively lower cost of care in government hospitals the outcome and process elements are still crucial in determining which sector patients prefer. These two elements seem to have influenced patronage for private practices of dual practitioners.

Factors Contributing to Rationed Nursing Care in the Slovak Republic—A Secondary Analysis of Quantitative Data

Rationed nursing care is a significant problem in healthcare facilities worldwide. Awareness of contributing factors to rationed care might support the development and implementation of strategies for reducing this phenomenon from clinical practice. The study examined the association between selected hospital, unit, and staff variables and the prevalence of rationed nursing care. Secondary analysis of cross-sectional data collected between December 2017 and July 2018 from 895 registered nurses in seven acute care hospitals in the Slovak Republic was performed. Data were collected using the questionnaire Perceived Implicit Rationing of Nursing and analyzed by descriptive and inferential statistics in the statistical program SPSS 25.0. Statistically significant associations were found between rationed nursing care and unit type, education, shift type, nurses’ experience in the current unit, overtime hours, missed shifts, intention to leave the position, perceived staff adequacy, quality of patient care, and job satisfaction. Differences in rating rationed nursing care, quality of patient care, and job satisfaction were identified based on hospital type. Together with top hospital management, nurse managers should develop targeted interventions focusing on mitigating rationed nursing care from the clinical practice with a focus placed on university hospitals. Quality and safe care might be ensured through constant monitoring of the quality of patient care and job satisfaction of nurses as these factors significantly predicted the estimates of rationed nursing care.

Care Quality, Patient Safety, and Nurse Outcomes at Hospitals Serving Economically Disadvantaged Patients: A Case for Investment in Nursing

We sought to evaluate if better work environments or staffing were associated with improvements in care quality, patient safety, and nurse outcomes across hospitals caring for different proportions of patients who are economically disadvantaged. Few actionable approaches for hospitals with quality and resource deficits exist. One solution may be to invest in the nurse work environment and staffing. This cross-sectional study utilized secondary data from 23,629 registered nurses in 503 hospitals from a four-state survey collected in 2005–2008. Each 10% increase in the proportion of patients who are economically disadvantaged was associated with 27% and 22% decreased odds of rating unit-level care quality as excellent and giving an “A” safety grade, respectively. Each 10% increase was also associated with 9%, 25%, and 11% increased odds of job dissatisfaction, intent to leave, and burnout, respectively. The work environment had the largest association with each outcome. Accounting for the nurse work environment lessened or eliminated the negative outcomes experienced at hospitals serving high proportions of patients who are economically disadvantaged. Leaders at hospitals serving high proportions of patients who are economically disadvantaged, as well as state and federal policymakers, should work to improve quality, safety, and nurse outcomes by strengthening nurse work environments. Improving work environments highlights the role of nursing in the health care system, and policies focused on work environments are needed to improve the experiences of patients and nurses, especially at hospitals that care for many patients who are economically disadvantaged.