Quality of Care in the Cirrhotic Patient.
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ABSTRACT:
SUBMITTER: Volk ML
PROVIDER: S-EPMC4855166 | biostudies-other | 2016
REPOSITORIES: biostudies-other
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Project description:In the past, patients with liver cirrhosis were thought to be prone to increased bleeding risk. However, those with compensated liver cirrhosis actually have normal coagulative balance, which can become altered when liver function worsens, or infection, bleeding, or acute kidney insufficiency occur. When this happens, it is now recognized that patients with liver cirrhosis are at higher risk of thrombotic rather than haemorrhagic complications. Anticoagulation plays a favourable role both when used therapeutically or prophylactically. Successful anticoagulation is associated with a lower rate of decompensation and with improved survival. To date, treatment has involved the use of low molecular weight heparins and vitamin K antagonists. Preliminary data suggest that novel non-vitamin K antagonist oral anticoagulants can be used safely in patients with liver cirrhosis.
| S-EPMC7001584 | biostudies-literature
Project description:BackgroundChronic liver disease especially liver cirrhosis is one of the medical problems that substantially reduces the quality of life of its victims. Because of the chronic and irreversible nature of the disease, it needs self-care programs to be developed according to client's needs and to maintain their independence and sense of well-being. The purpose of this study was to determine the effects of a self-care educational program on Quality of Life (QoL) of a sample of Iranian cirrhotic patients.MethodsA quasi-experimental study was conducted on 44 cirrhotic patients in Tehran Hepatitis Center. Longitudinal case registry and random allocation technique were used to divide the sample into experimental (n = 21) and control (n = 23) groups. Chronic liver disease questionnaire (CLDQ) was used for measuring the quality of life. The experimental group was given a questionnaire to assess their educational needs. A self-care educational program was conducted and the patients were followed for 3 months. Then the quality of life of both groups was compared using descriptive and analytical statistics.ResultsThe experimental and control groups were the same concerning the effective factors on the quality of life, such as age, sex, etc (P > 0.05). There was no significant difference between QOL mean score of both groups before the intervention, however the QoL significantly improved in the experimental group after the intervention (P = 0.001), while the QoL decreased in control group.ConclusionThe result of the present study confirmed the positive effects of the educational and self care programs on the QoL of cirrhotic patients. Extensive educational and self-care programs along with long-term follow up such as the program conducted in this study are suggested.
| S-EPMC1156929 | biostudies-literature
Project description:Pain management in patients with cirrhosis is a difficult clinical challenge for health care professionals, and few prospective studies have offered an evidence-based approach. In patients with end-stage liver disease, adverse events from analgesics are frequent, potentially fatal, and often avoidable. Severe complications from analgesia in these patients include hepatic encephalopathy, hepatorenal syndrome, and gastrointestinal bleeding, which can result in substantial morbidity and even death. In general, acetaminophen at reduced dosing is a safe option. In patients with cirrhosis, nonsteroidal anti-inflammatory drugs should be avoided to avert renal failure, and opiates should be avoided or used sparingly, with low and infrequent dosing, to prevent encephalopathy. For this review, we searched the available literature using PubMed and MEDLINE with no limits.
| S-EPMC2861975 | biostudies-literature
Project description:Engaging health care staff in new quality improvement programs is challenging.We developed 2 virtual patient (VP) avatars in the context of a clinic-level quality improvement program. We sought to determine differences in preferences for VPs and the perceived influence of interacting with the VP on clinical staff engagement with the quality improvement program.Using a participatory design approach, we developed an older male smoker VP and a younger female smoker VP. The older male smoker was described as a patient with cardiovascular disease and was ethnically ambiguous. The female patient was younger and was worried about the impact of smoking on her pregnancy. Clinical staff were allowed to choose the VP they preferred, and the more they engaged with the VP, the more likely the VP was to quit smoking and become healthier. We deployed the VP within the context of a quality improvement program designed to encourage clinical staff to refer their patients who smoke to a patient-centered Web-assisted tobacco intervention. To evaluate the VPs, we used quantitative analyses using multivariate models of provider and practice characteristics and VP characteristic preference and analyses of a brief survey of positive deviants (clinical staff in practices with high rates of encouraging patients to use the quit smoking innovation).A total of 146 clinical staff from 76 primary care practices interacted with the VPs. Clinic staff included medical providers (35/146, 24.0%), nurse professionals (19/146, 13.0%), primary care technicians (5/146, 3.4%), managerial staff (67/146, 45.9%), and receptionists (20/146, 13.7%). Medical staff were mostly male, and other roles were mostly female. Medical providers (OR 0.031; CI 0.003-0.281; P=.002) and younger staff (OR 0.411; CI 0.177-0.952; P=.038) were less likely to choose the younger, female VP when controlling for all other characteristics. VP preference did not influence online patient referrals by staff. In high-performing practices that referred 20 or more smokers to the ePortal (13/76), the majority of clinic staff were motivated by or liked the virtual patient (20/26, 77%).Medical providers are more likely motivated by VPs that are similar to their patient population, while nurses and other staff may prefer avatars that are more similar to them.
| S-EPMC5332834 | biostudies-other
Project description:BackgroundIn this study, we aimed to develop and validate an instrument that could be used by patients with cancer to evaluate their quality of palliative care.MethodsDevelopment of the questionnaire followed the four-phase process: item generation and reduction, construction, pilot testing, and field testing. Based on the literature, we constructed a list of items for the quality of palliative care from 104 quality care issues divided into 14 subscales. We constructed scales of 43 items that only the cancer patients were asked to answer. Using relevance and feasibility criteria and pilot testing, we developed a 44-item questionnaire. To assess the sensitivity and validity of the questionnaire, we recruited 220 patients over 18 years of age from three Korean hospitals.ResultsFactor analysis of the data and fit statistics process resulted in the 4-factor, 32-item Quality Care Questionnaire-Palliative Care (QCQ-PC), which covers appropriate communication with health care professionals (ten items), discussing value of life and goals of care (nine items), support and counseling for needs of holistic care (seven items), and accessibility and sustainability of care (six items). All subscales and total scores showed a high internal consistency (Cronbach alpha range, 0.89 to 0.97). Multi-trait scaling analysis showed good convergent (0.568-0.995) and discriminant (0.472-0.869) validity. The correlation between the total and subscale scores of QCQ-PC and those of EORTC QLQ-C15-PAL, MQOL, SAT-SF, and DCS was obtained.ConclusionThis study demonstrates that the QCQ-PC can be adopted to assess the quality of care in patients with cancer.
| S-EPMC5836356 | biostudies-literature
Project description:BackgroundThis paper describes an integrated series of functional, clinical, and discharge post-acute care (PAC) quality indicators (QIs) and an examination of the distribution of the QIs in skilled nursing facilities (SNF) across the US. The indicators use items available in interRAI based assessments including the MDS 3.0 and are designed for use in in-patient post-acute environments that use the assessments.MethodsData Source: MDS 3.0 computerized assessments mandated for all patients admitted to US skilled nursing facilities (SNF) in 2012. In total, 2,380,213 patients were admitted to SNFs for post-acute care. Definition of the QI numerator, denominator and covariate structures were based on MDS assessment items. A regression strategy modeling the "discharge to the community" PAC QI as the dependent variable was used to identify how to bring together a subset of seven candidate PAC QIs for inclusion in a summary scale. Finally, the distributional property of the summary scale (the PAC QI Summary Scale) across all facilities was explored.ResultsThe risk-adjusted PAC QIs include indicators of improved status, including measures of early, middle, and late-loss functional performance, as well as measures of walking and changed clinical status and an overall summary functional scale. Many but not all patients demonstrated improvement from baseline to follow-up. However, there was substantial inter-state variation in the summary QI scores across the SNFs.ConclusionsThe set of PAC QIs consist of five functional, two discharge and eight clinical measures, and one summary scale. All QIs can be derived from multiple interRAI assessment tools, including the MDS 2.0, interRAI-LTCF, MDS 3.0, and the interRAI-PAC-Rehab. These measures are appropriate for wide distribution in and out of the United States, allowing comparison and discussion of practices associated with better outcomes.
| S-EPMC6042453 | biostudies-literature
Project description:BACKGROUND: Assessing physicians' clinical performance using statistically sound, evidence-based measures is challenging. Little research has focused on methodological approaches to setting performance standards to which physicians are being held accountable. OBJECTIVE: Determine if a rigorous approach for setting an objective, credible standard of minimally-acceptable performance could be used for practicing physicians caring for diabetic patients. DESIGN: Retrospective cohort study. PARTICIPANTS: Nine hundred and fifty-seven physicians from the United States with time-limited certification in internal medicine or a subspecialty. MAIN MEASURES: The ABIM Diabetes Practice Improvement Module was used to collect data on ten clinical and two patient experience measures. A panel of eight internists/subspecialists representing essential perspectives of clinical practice applied an adaptation of the Angoff method to judge how physicians who provide minimally-acceptable care would perform on individual measures to establish performance thresholds. Panelists then rated each measure's relative importance and the Dunn-Rankin method was applied to establish scoring weights for the composite measure. Physician characteristics were used to support the standard-setting outcome. KEY RESULTS: Physicians abstracted 20,131 patient charts and 18,974 patient surveys were completed. The panel established reasonable performance thresholds and importance weights, yielding a standard of 48.51 (out of 100 possible points) on the composite measure with high classification accuracy (0.98). The 38 (4%) outlier physicians who did not meet the standard had lower ratings of overall clinical competence and professional behavior/attitude from former residency program directors (p = 0.01 and p = 0.006, respectively), lower Internal Medicine certification and maintenance of certification examination scores (p = 0.005 and p < 0.001, respectively), and primarily worked as solo practitioners (p = 0.02). CONCLUSIONS: The standard-setting method yielded a credible, defensible performance standard for diabetes care based on informed judgment that resulted in a reasonable, reproducible outcome. Our method represents one approach to identifying outlier physicians for intervention to protect patients.
| S-EPMC3077491 | biostudies-other
Project description:The relationship between patient satisfaction and surgical quality is unclear for US hospitals. Using national data, we examined if hospitals with high patient satisfaction have lower levels of performance on accepted measures of the quality and efficiency of surgical care.Federal policymakers have made patient satisfaction a core measure for the way hospitals are evaluated and paid through the value-based purchasing program. There is broad concern that performance on patient satisfaction may have little or even a negative correlation with the quality of surgical care, leading to potential trade-offs in efforts to improve patient experience with other surgical quality measures.We used the Hospital Consumer Assessment of Healthcare Providers and Systems survey data from 2010 and 2011 to assess performance on patient experience. We used national Medicare data on 6 common surgical procedures to calculate measures of surgical efficiency and quality: risk-adjusted length of stay, process score, risk-adjusted mortality rate, risk-adjusted readmission rate, and a composite z score across all 4 metrics. Multivariate models adjusting for hospital characteristics were used to assess the independent relationships between patient satisfaction and measures of surgical efficiency and quality.Of the 2953 US hospitals that perform one of these 6 procedures, the median patient satisfaction score was 69.5% (interquartile range, 63%-75.5%). Length of stay was shorter in hospitals with the highest levels of patient satisfaction (7.1 days vs 7.7 days, P < 0.001). Adjusting for procedural volume and structural characteristics, institutions in the highest quartile of patient satisfaction had the higher process of care performance (96.5 vs 95.5, P < 0.001), lower readmission rates (12.3% vs 13.6%, P < 0.001), and lower mortality (3.1% vs 3.6%) than those in the lowest quartile. Hospitals with high patient satisfaction also had a higher composite score for quality across all measures (P < 0.001).Among US hospitals that perform major surgical procedures, hospitals with high patient satisfaction provided more efficient care and were associated with higher surgical quality. Our findings suggest there need not be a trade-off between good quality of care for surgical patients and ensuring a positive patient experience.
| S-EPMC4248016 | biostudies-literature
Project description:AimsIt has long been held that high-quality care has both technical and interpersonal aspects. The nature and strength of any association between both aspects remain poorly explored. This study investigated the associations between diabetes patients' reports of receiving recommended care (as measures of technical quality) and their experience and ratings (as measures of interpersonal care).MethodsUsing data from a cross section of 3096 patients with diabetes nested within 24 diabetes-care-networks, we conducted multilevel regression analysis of the relationships between nine indicators of receiving care recommended in practice guidelines and: six scales of patient experience and global ratings of general practitioner, nurses, and overall diabetes care.ResultsOn average, reporting having received recommended care was associated with reporting better patient experience and ratings. The extent and frequencies of these associations varied across the different care processes. Receiving foot examination, physical activity advice, smoking status check, eye examination, and HbA1c testing, but not nutritional advice, urine, cholesterol or blood pressure checks, were statistically associated with better patient experience and global ratings. Those who received HbA1c testing rated their overall care 1.002 points higher (95% confidence interval: 0.726-1.278) on a scale of 0-10 than those who did not.ConclusionsHigher self-reported technical quality of care in diabetes appears to be frequently but not always associated with better experiences and ratings. It is possible that the former leads to the latter and/or that both share a common cause within providers. Both care aspects do not seem interchangeable during performance assessment.
| S-EPMC5060680 | biostudies-literature
Project description:PurposeEven though pay-for-performance programs are being rapidly implemented, little is known about how patient complexity affects practice-level performance assessment in rural settings. We sought to determine the association between patient complexity and practice-level performance in the rural United States.Basic proceduresUsing baseline data from a trial aimed at improving diabetes care, we determined factors associated with a practice's proportion of patients having controlled diabetes (hemoglobin A1c<or=7%): patient socioeconomic factors, clinical factors, difficulty with self-testing of blood glucose, and difficulty with keeping appointments. We used linear regression to adjust the practice-level proportion with A1c controlled for these factors. We compared practice rankings using observed and expected performance and classified practices into hypothetical pay-for-performance categories.Main findingsRural primary care practices (n=135) in 11 southeastern states provided information for 1641 patients with diabetes. For practices in the best quartile of observed control, 76.1% of patients had controlled diabetes vs 19.3% of patients in the worst quartile. After controlling for other variables, proportions of diabetes control were 10% lower in those practices whose patients had the greatest difficulty with either self testing or appointment keeping (p<.05 for both). Practice rankings based on observed and expected proportion of A1c control showed only moderate agreement in pay-for-performance categories (kappa=0.47; 95% confidence interval, 0.32-0.56; p<001).Principal conclusionsBasing public reporting and resource allocation on quality assessment that does not account for patient characteristics may further harm this vulnerable group of patients and physicians.
| S-EPMC3156053 | biostudies-literature