Quality indicators in hemodialysis: A 5-year experience of national campaigns in France.

BACKGROUND: End stage kidney disease (ESKD) is associated with increased morbidity and mortality. Hemodialysis (HD) is the main technique used for kidney replacement therapy. Dialyzed patients are expected to live less than one half as long as their counterparts without ESKD. Improving quality of care may help to improve mortality in this population. METHODS: The French National Authority for Health has carried out three consecutive national campaigns over 5 years for the assessment of quality indicators (QCI) during HD. QCI included anemia management, iron status evaluation, nutritional status assessment, and annual transplantation access. RESULTS: From 2013 to 2017, 227 health facilities participated, and 33,319 files were analyzed. Median age was 72 years old (IQR25-75 = 61-81), and 58.25% of patients were men. Median time in HD was 39.4 months (IQR25-75 = 20.7-72.7). Most of the patients underwent in-center HD (85.41%). Overweight and obese patients accounted, respectively, for 28.39% and 21.32%, and malnutrition was present in 38.61%. A contra-indication for renal transplantation was found in 68.3% of patients. All QCI improved over 5 years. CONCLUSION: Developing QCI based on guidelines is crucial to assure appropriate care of HD patients. Repeating campaigns over 5 years in France improves the quality of care among physicians.

L'enquête nationale e-Satis, mesurer la satisfaction et l'expérience des patients.

E-SATIS NATIONAL SURVEY, MEASURING PATIENT SATISFACTION AND EXPERIENCE.: Since 2015, the French National Health Authority has been managing and rolling out the national programme for measuring patient satisfaction and experience, called 'e-Satis'. Thanks to this evaluation, it has produced, for all participating healthcare facilities, detailed and continuous results, in order to guide the improvement of the quality of practices and the organisation of care. The National Health Authority must now look to consolidate the programme, notably through greater patient participation and the appropriation of the results by professionals.

Quality indicators for acute myocardial infarction: A position paper of the Acute Cardiovascular Care Association.

Evaluation of quality of care is an integral part of modern healthcare, and has become an indispensable tool for health authorities, the public, the press and patients. However, measuring quality of care is difficult, because it is a multifactorial and multidimensional concept that cannot be estimated solely on the basis of patients' clinical outcomes. Thus, measuring the process of care through quality indicators (QIs) has become a widely used practice in this context. Other professional societies have published QIs for the evaluation of quality of care in the context of acute myocardial infarction (AMI), but no such indicators exist in Europe. In this context, the European Society of Cardiology (ESC) Acute Cardiovascular Care Association (ACCA) has reflected on the measurement of quality of care in the context of AMI (ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI)) and created a set of QIs, with a view to developing programmes to improve quality of care for the management of AMI across Europe. We present here the list of QIs defined by the ACCA, with explanations of the methodology used, scientific justification and reasons for the choice for each measure.

Factors associated with the length of stay of patients discharged from emergency department in France.

OBJECTIVES: The length of stay in the emergency department (ED) has been proposed as an indicator of performance in many countries. We conducted a survey of length of stay in two large areas in France and tested the hypothesis that patient and ED-related variables may influence it. PATIENTS AND METHODS: During 2007, we examined lengths of stay in ambulatory patients, that is, excluding admitted patients. The following variables were considered: (a) at the patient level, age, sex, the day and month of the visit, and the French clinical classification of emergency patients (CCEP) class; (b) at the ED level, annual ED total number of visits, mean age, the proportions of patients less than 15 and more than 75 years, and the proportions of admitted and clinically stable patients with CCEP class 1 and 2. A multilevel hierarchical analysis was carried out. RESULTS: We analyzed 988 591 visits in 53 EDs. The ED-specific median length of stay was 98 (IQR: 62-137) min and the ED-specific median proportion of patients with length of stay of more than 4 h was 15 (5-24) %. There was a strong correlation between the ED-specific median length of stay and the ED-specific proportion of patients with a length of stay of more than 4 h (R=0.96, P<0.001). Using a multilevel analysis, only three variables were associated significantly with the length of stay: the age and the CCEP class of the patient, and the ED census. CONCLUSION: We observed that the length of stay in the ED needs to be stratified by case mix and the total number of visits of the ED.

Hospital performance based on treatment delays: comparison of ranking methods.

BACKGROUND: Reducing time-to-care is crucial in many acute and chronic diseases. Quality indicators based on target delays derived from guidelines are used to compare hospital performance but there is no accepted methodology for comparing performance when no target delay has been established. AIM: To explore by different statistical methods the uncertainty in hospital comparisons that are based on delay indicators, when no target delay is available. METHODS: Data for hospital door-to-needle time were extracted from a 2010 study of 1699 patients in 57 hospitals with ST-elevated myocardial infarction. We determined whether the times in each hospital were statistically different from the overall mean time or the median time for all hospitals by (i) one-way analysis of variance (ANOVA), (ii) non-parametric ANOVA with Nelson-Hsu adjustment (ANOVA R) and (iii) the proportional hazard model (PHM). We also tested for the assumptions underlying the methods: normal distribution for ANOVA, homogeneity of variances (homoscedasticity) for ANOVA and ANOVA R, and proportionality for PHM. RESULTS: Door-to-needle times were available for 889 patients in 44 hospitals. Data distribution was not Gaussian. Test assumptions were verified for ANOVA R (homoscedasticity) for one data subset (>48-h times (48H) excluded) and for PHM (proportionality) for two data subsets (48H or >95th percentile (P95) times excluded). The same five significantly better performers were identified in each case (although ANOVA R missed one). ANOVA R (48H) identified two significantly poorer performers, PHM (48H) identified three and PHM (P95) just one. Poorer performers differed according to method. CONCLUSIONS: The tested statistical methods yielded broadly similar results but no method was truly satisfactory. A transparency statement should therefore always specify the ranking method used to compare hospital performance.

Symptom-to-needle times in ST-segment elevation myocardial infarction: shortest route to a primary coronary intervention facility.

BACKGROUND: Primary percutaneous coronary intervention (PCI) is the preferred management for patients with acute ST-segment elevation myocardial infarction (STEMI) if performed in a timely manner by experienced providers. Patients can access a PCI facility by three routes: prehospital STEMI diagnosis by emergency medical services (EMS) and direct transport by EMS to a PCI facility (EMS-PCI); visit to a hospital emergency department (ED) followed by referral to an on-site PCI facility (ED-PCI); or transfer from the ED to a PCI facility in another hospital (ED-transfer-PCI). AIMS: To assess the implementation rate in France of the guidelines recommending that STEMI patients be transported by EMS to a PCI facility and to compare the times between symptom onset and PCI for these three routes. METHODS: We used the results of the pilot testing of a national quality indicator programme on STEMI in 64 hospitals, providing data on patient characteristics, referral route and symptom-onset-to-needle time. We compared delays for each route in a Cox proportional-hazard model. RESULTS: In a population of 1217 patients, median symptom-onset-to-needle time was 186minutes (Q1 133; Q3 292) for the EMS-PCI route, 237minutes (Q1 165; Q3 368) for the ED-PCI route and 305minutes (Q1 230; Q3 570) for the ED-transfer-PCI route. A total of 70.8% of patients were transported by EMS as recommended. After adjustment for age, symptom onset period (weekends/nights) and history of cardiovascular disease, the EMS-PCI route was associated with the shortest symptom-onset-to-needle times. The hazard ratio was 0.71 [0.59-0.86] for the ED-PCI route and 0.67 [0.52-0.86] for the ED-transfer-PCI route. CONCLUSION: STEMI patients receive prompter care after prehospital diagnosis and direct transport to a PCI facility by EMS than by visiting a hospital ED. Use of this referral route should be further encouraged in France as approximately one-third of STEMI patients are still presenting directly to the ED.

Hospital case volume and appropriate prescriptions at hospital discharge after acute myocardial infarction: a nationwide assessment.

BACKGROUND: In acute myocardial infarction, the relationship between volume and quality indicators (QIs) is poorly documented. Through a nationwide assessment of QIs at discharge repeated for 3 years, we aimed to quantify the relationship between volume and QIs in survivors after acute myocardial infarction. METHODS AND RESULTS: Almost all healthcare centers in France participated. Medical records were randomly selected. Data collection was performed by an independent group. QIs for acute myocardial infarction were defined by an expert consensus group as appropriate prescription at discharge of aspirin, clopidogrel, ß-blocker, statin, and an angiotensin-converting enzyme inhibitor in patients with left ventricular ejection fraction <0.40. A composite QI was calculated through the use of the all-or-none method. Volume was classified into 7 categories based on the number of admissions for acute myocardial infarctions in 2008 (centers with <10 acute myocardial infarctions were excluded). Odds ratios adjusted for age and sex with 95% confidence interval for volume categories were calculated by use of logistic regression for each QI. Temporal changes were tested in centers that participated in all 3 campaigns. A total of 46 390 records were examined: 18 159 in 2008, 12 837 in 2009, and 15 394 in 2010. Two hundred ninety-one centers were eligible for the temporal analysis. There was a significant increase between 2008 and 2009 in appropriate prescription of antiplatelet agents, ß-blockers, angiotensin-converting enzyme inhibitor, statins at discharge, and the composite indicator. Similarly, a significant increase was observed between 2009 and 2010 in appropriate prescription of angiotensin-converting enzyme inhibitor and ß-blockers and in the composite QI. Compared with a volume of >300, a significantly lower rate of all QIs was observed in centers with the lowest volume. Odds ratios progressively decreased with increasing volume. Despite a significant increase in the composite QI over the 3 years, a significant relationship persisted between volume and quality of care. CONCLUSIONS: Analysis of QIs at discharge demonstrates the existence of a relationship between volume and appropriate prescriptions at discharge. Centers with the highest volume perform better on quality measures than centers with lower volumes. Temporal analysis over 3 consecutive years confirms this relationship and shows that it persists despite improvement in QIs between 2008 and 2010.

Method for developing national quality indicators based on manual data extraction from medical records.

Developing quality indicators (QI) for national purposes (eg, public disclosure, paying-for-performance) highlights the need to find accessible and reliable data sources for collecting standardised data. The most accurate and reliable data source for collecting clinical and organisational information still remains the medical record. Data collection from electronic medical records (EMR) would be far less burdensome than from paper medical records (PMR). However, the development of EMRs is costly and has suffered from low rates of adoption and barriers of usability even in developed countries. Currently, methods for producing national QIs based on the medical record rely on manual extraction from PMRs. We propose and illustrate such a method. These QIs display feasibility, reliability and discriminative power, and can be used to compare hospitals. They have been implemented nationwide in France since 2006. The method used to develop these QIs could be adapted for use in large-scale programmes of hospital regulation in other, including developing, countries.

Suitability of three indicators measuring the quality of coordination within hospitals.

BACKGROUND: Coordination within hospitals is a major attribute of medical care and influences quality of care. This study tested the validity of 3 indicators covering two key aspects of coordination: the transfer of written information between professionals (medical record content, radiology exam order) and the holding of multidisciplinary team meetings during treatment planning. METHODS: The study was supervised by the French health authorities (COMPAQH project). Data for the three indicators were collected in a panel of 30 to 60 volunteer hospitals by 6 Clinical Research Assistants. The metrological qualities of the indicators were assessed: (i) Feasibility was assessed using a grid of 19 potential problems, (ii) Inter-observer reliability was given by the kappa coefficient () and internal consistency by Cronbach's alpha test, (iii) Discriminatory power was given by an analysis of inter-hospital variability using the Gini coefficient as a measure of dispersion. RESULTS: Overall, 19281 data items were collected and analyzed. All three indicators presented acceptable feasibility and reliability (, 0.59 to 0.97) and showed wide differences among hospitals (Gini, 0.08 to 0.11), indicating that they are suitable for making comparisons among hospitals. CONCLUSION: This set of 3 indicators provides a proxy measurement of coordination. Further research on the indicators is needed to find out how they can generate a learning process. The medical record indicator has been included in the French national accreditation procedure for healthcare organisations. The two other indicators are currently being assessed for inclusion.

Antischistosomal efficacy of artesunate combination therapies administered as curative treatments for malaria attacks.

Artesunate is a highly effective antimalarial and there is some evidence that it is also active against schistosome infections. We therefore investigated whether treatment with artesunate of acute malaria in Senegalese children had an impact on their level of infection with Schistosoma haematobium. Twenty-seven children who were entered into a clinical trial of antimalaria treatment were excreting S. haematobium eggs in their urine on the day of treatment. Fifteen children received a combination of a single dose of sulfadoxine/pyrimethamine together with three daily doses of artesunate (4 mg/kg); the remaining 12 children received three daily doses of amodiaquine and artesunate. The overall cure rate and reduction in the mean number of excreted eggs at 28 days post treatment were 92.6% and 94.5%, respectively. Our findings indicate that artesunate, in addition to being a very effective treatment for uncomplicated malaria, can also sharply reduce the S. haematobium loads harboured by pre-school African children.