[Indication for mitral valve interventions: Development of a quality indicator for external hospital quality assurance]. / Indikationsstellung bei Mitralklappeneingriffen: Entwicklung eines Qualitätsindikators im Rahmen der externen stationären Qualitätssicherung.

BACKGROUND: The indication for a mitral valve intervention is an important patient-relevant parameter for the assessment of process quality and the comparison of healthcare providers. In this article, we describe the development of a corresponding quality indicator for an external hospital quality assurance (QA) procedure in Germany. METHODS: An expert panel was set up by the aQua Institute to assist with the development of a QA procedure for mitral valve interventions and the associated quality indicators. In a comprehensive, systematic literature and evidence research, the American and European guidelines were identified as the best evidence available. Especially the more current American guideline formed the basis on which a quality indicator dealing with the correct indication for a mitral valve intervention was developed. RESULTS: The developed quality indicator assesses the proportion of patients for whom an indication for a mitral valve intervention was determined in compliance with guideline recommendations. The indicator differentiates between surgical and catheter-based procedures. To determine whether or not the indication was correct, different medical parameters are included, such as, for example, type of mitral valve defect, etiology of the disease, severity of symptoms, valve morphology (e. g., mitral valve area), valve hemodynamics and comorbidity, which healthcare providers have to document. CONCLUSION: The documentation for the developed quality indicator is considerable. Nonetheless, its relevance is undeniable because it allows the user to determine whether a surgical or catheter-based mitral valve intervention was necessary and performed according to guideline recommendations. In the first year of its implementation, this indicator should be evaluated for further improvement and simplification of assessment.

Development of quality indicators and data assessment strategies for the prevention of central venous catheter-related bloodstream infections (CRBSI).

BACKGROUND: The number of catheter related bloodstream infections (CRBSI) could be reduced and the outcome improved if specific standards in the quality of care were maintained. Therefore, the development of quality assurance (QA) procedures was commissioned to be included in the national mandatory QA programme in Germany. METHODS: Indicators representing quality deficiencies and potential for improvement of quality in relation to prevention and management of central venous catheters (CVC) were developed by (1) evidence-based literature searches and the compiling of an indicator register; (2) a multi-professional expert panel including patient representatives who selected indicators from this register by using a modified RAND/UCLA Appropriateness Method; (3) defining methods for data assessment, risk adjustment and feedback of indicator results to service providers; and (4) consulting all relevant medical societies and other stakeholders with regard to the QA procedures that had been developed. RESULTS: Thirty-two indicators for CRBSI prevention and management were eventually approved by the expert panel. These indicators represent quality of care at predefined points with regard to indication, insertion and care of CVCs, management of sepsis, general hygiene and training of health care personnel. Fourteen indicators represent processes, together with 7 representing structures and 11 outcomes. For assessing these indicators, data was obtained from four sources: claims data from health insurance funds, routine claims data from hospital electronic information systems, case specific longitudinal documentation from service providers and cross-sectional annual assessment of structures. CONCLUSIONS: It was possible to develop indicators for mandatory QA procedures on CRBSI that take into account the different perspectives of all stakeholders involved. Despite efforts to use routine data for documentation wherever possible, most indicators required extra documentation.

Case Numbers and Process Quality in Breast Surgery in Germany: A Retrospective Analysis of Over 150,000 Patients From 2013 to 2014.

BACKGROUND: Numerous studies from around the world have shown a positive association between case numbers and the quality of medical care. The evidence to date suggests that conformity to guidelines for the treatment of patients with breast cancer is better in German hospitals that have higher case numbers. METHODS: We used data obtained by an external program for quality assurance in inpatient care (externe stationäre Qualitätssicherung, esQS) for the years 2013 and 2014 to investigate seven process indicators in the area of breast surgery, including histologic confirmation of the diagnosis before definitive treatment, axillary dissection as recommended by the guidelines, and an appropriate temporal interval between diagnosis and operation. Case numbers were categorized with the aid of various threshold values. Moreover, subgroup analyses were carried out for patients under age 65, patients in good general health, patients without lymph-node involvement, and patients with a tumor size pT0 or pT1 or an overall tumor size less than 5 cm. RESULTS: Data on 153,475 patients from 939 hospitals were analyzed. Six of seven indicators had values that were better overall, to a statistically significant extent, in hospitals with higher case numbers. Although this relationship was not consistently seen, the worst results were generally found in the category with the lowest case numbers. Similar though less striking results were obtained in the subgroup analyses. An exception to the general finding was that, in hospitals with higher case numbers, the interval between diagnosis and operation was more often longer than three weeks. CONCLUSION: Guideline adherence is higher in hospitals that treat more cases. The present study does not address the question whether this, in turn, affects morbidity or mortality. To improve process quality in peripheral hospitals, the quality assurance program should be continued.