Background: Performance measures are used for assessing quality of care. Higher performance shown by these measures is expected to reflect better care, but little is known whether they predict better ...patient outcomes. Objective: To assess the predictive value of performance measures of glucose management on glycemie control, and evaluate the impact of patient characteristics on this association. Research Design: Cohort study (2007-2009). Subjects: A total of 15,454 type 2 diabetes patients (mean age, 66.5 y; 48% male) from the GIANTT cohort. Measures: We included performance measures assessing frequency of HbAlc monitoring, glucose-lowering treatment status, and treatment intensification. Associations between performance and glycemie control were tested using multivariate linear regression adjusted for confounding, reporting estimated differences in HbAlc with 95% confidence intervals (CI). Impact of patient characteristics was examined through interactions. Results: Annual HbAlc monitoring was associated with better glycemie control when compared with no such monitoring (HbAlc -0.29%; 95% CI -0.37, -0.22). This association lost significance in patients with lower baseline HbAlc, older age, and without macrovascular comorbidity. Treatment status was associated with better glycemie control only in patients with elevated baseline HbAlc. Treatment intensification after elevated HbAlc levels was associated with better glycemie control compared with no intensification (HbA1c -0.21; 95% CI -0.26, -0.16). Conclusions: Performance measures of annual HbA1c monitoring and of treatment intensification did predict better patient outcomes, whereas the measure of treatment status did not. Predictive value of annual monitoring and of treatment status varied across patient characteristics, and it should be used with caution when patient characteristics cannot be taken into account.
Objective
Head and neck squamous cell carcinomas (HNSCC) are rapidly developing tumours, and substantial delay in treatment initiation is associated with decreased overall survival. The effect of ...delay on health‐related quality of life (HRQOL) is unknown. The aim of this study was to assess the impact of delay on QOL and overall survival.
Methods
Patients with mucosal HNSCC were prospectively included. HRQOL and 2‐year overall survival were analysed using linear mixed‐model analyses and cox regression, respectively. Delay was defined as care pathway interval (CPI) of ≥30 days between first consultation and treatment initiation.
Results
Median CPI was 39 days for the 173 patients included. A trend towards higher HRQOL‐scores (indicating better HRQOL) during 2‐year follow‐up for patients with delay in treatment initiation was visible in the adjusted models (HRQOL summary score—β: 2.62, 95% CI: 0.57–4.67, p = 0.012). Factors associated with decreased overall survival were moderate comorbidities (HR: 5.10, 95% CI: 1.65–15.76, p = 0.005) and stage‐IV tumours (HR: 12.37, 95% CI: 2.81–54.39, p = 0.001). Delay was not associated with worse overall survival.
Conclusion
Timely treatment initiation is challenging, especially for patients with advanced tumours and initial radiotherapy treatment. Encountering delay in treatment initiation did not result in clinically relevant differences in HRQOL‐scores or decreased overall survival during 2‐year follow‐up.
To assess whether quality indicators for treatment of cardiovascular and renal risk factors are associated with short-term outcomes in patients with diabetes.
A prospective cohort study using linear ...regression adjusting for confounders.
The GIANTT database (Groningen Initiative to Analyse Type 2 Diabetes Treatment) containing data from primary care medical records from The Netherlands.
15 453 patients with type 2 diabetes mellitus diagnosed before 1 January 2008. Mean age 66.5 years, 47.5% men.
Quality indicators assessing current treatment (CT) status or treatment intensification (TI) for patients with diabetes with elevated cardiovascular or renal risk factors.
Low-density lipoprotein cholesterol (LDL-C), systolic blood pressure (SBP), and albumin:creatinine ratio (ACR) before and after assessment of treatment quality.
Use of lipid-lowering drugs was associated with better LDL-C levels (-0.41 mmol/litre; 95% CI -0.48 to -0.34). Use of blood pressure-lowering drugs and use of renin-angiotensin system inhibitors in patients with elevated risk factor levels was not associated with better SBP and ACR outcomes, respectively. TI was also associated with better LDL-C (-0.82 mmol/litre; CI -0.93 to -0.71) in patients with elevated LDL-C levels, and with better SBP (-1.26 mm Hg; CI -2.28 to -0.24) in patients with two elevated SBP levels. Intensification of albuminuria-lowering treatment showed a tendency towards better ACR (-2.47 mmol/mg; CI -5.32 to 0.39) in patients with elevated ACR levels.
Quality indicators of TI were predictive of better short-term cardiovascular and renal outcomes, whereas indicators assessing CT status showed association only with better LDL-C outcome.
Differences in body composition in patients with COPD may have important prognostic value and may provide opportunities for patient-specific management. We investigated the relation of thoracic fat ...and muscle with computed tomography (CT)-measured emphysema and bronchial wall thickening.
Low-dose baseline chest CT scans from 1031 male lung cancer screening participants from one site were quantified for emphysema, bronchial wall thickening, subcutaneous fat, visceral fat and skeletal muscle. Body composition measurements were performed by segmenting the first slice above the aortic arch using Hounsfield unit thresholds with region growing and manual corrections. COPD presence and severity were evaluated with pre-bronchodilator spirometry testing.
Participants had a median age of 61.5 years (58.6-65.6, 25th-75th percentile) and median number of 38.0 pack-years (28.0-49.5); 549 (53.2%) were current smokers. Overall, 396 (38.4%) had COPD (256 Global Initiative for Chronic Obstructive Lung Disease (GOLD) 1, 140 GOLD 2-3). Participants with COPD had less subcutaneous fat, visceral fat and skeletal muscle (p<0.001 for all). With increasing GOLD stages, subcutaneous (p=0.005) and visceral fat values (p=0.004) were higher, and skeletal muscle was lower (p=0.004). With increasing severity of CT-derived emphysema, subcutaneous fat, visceral fat and skeletal muscle values were lower (p<0.001 for all). With increasing CT-derived bronchial wall thickness, subcutaneous and visceral fat values were higher (p<0.001 for both), without difference in skeletal muscle. All statistical relationships remained when adjusted for age, pack-years and smoking status.
COPD presence and emphysema severity are associated with smaller amounts of thoracic fat and muscle, whereas bronchial wall thickening is associated with fat accumulation.
To develop and validate a contrast-enhanced CT based classification tree model for classifying solid lung tumors in clinical patients into malignant or benign.
Between January 2015 and October 2017, ...827 pathologically confirmed solid lung tumors (487 malignant, 340 benign; median size, 27.0 mm, IQR 18.0-39.0 mm) from 827 patients from a dedicated Chinese cancer hospital were identified. Nodules were divided randomly into two groups, a training group (575 cases) and a testing group (252 cases). CT characteristics were collected by two radiologists, and analyzed using a classification and regression tree (CART) model. For validation, we used the decision analysis threshold to evaluate the classification performance of the CART model and radiologist's diagnosis (benign; malignant) in the testing group.
Three out of 19 characteristics margin (smooth; slightly lobulated/lobulated/spiculated), and shape (round/oval; irregular), subjective enhancement (no/uniform enhancement; heterogeneous enhancement) were automatically generated by the CART model for classifying solid lung tumors. The sensitivity, specificity, PPV, NPV, and diagnostic accuracy of the CART model is 98.5%, 58.1%, 80.6%, 98.6%, 79.8%, and 90.4%, 54.7%, 82.4% 98.5%, 74.2% for the radiologist's diagnosis by using three-threshold decision analysis.
Tumor margin and shape, and subjective tumor enhancement were the most important CT characteristics in the CART model for classifying solid lung tumors as malignant. The CART model had higher discriminatory power than radiologist's diagnosis. The CART model could help radiologists making recommendations regarding follow-up or surgery in clinical patients with a solid lung tumor.
ObjectivesInsight in the prescribing quality for patients with chronic kidney disease (CKD) in secondary care is limited. The aim of this study is to assess the prescribing quality in secondary care ...patients with CKD stages 3–5 and possible differences in quality between CKD stages.DesignThis was a retrospective cohort study.SettingData were collected at two university (n=569 and n=845) and one non-university nephrology outpatient clinic (n=1718) in the Netherlands.ParticipantsBetween March 2015 and August 2016, data were collected from patients with stages 3a–5 CKD seen at the clinics. Blood pressure measurements, laboratory measurements and prescription data were extracted from medical records. For each prescribing quality indicator, patients with incomplete data required for calculation were excluded.Outcome measuresPotentially appropriate prescribing of antihypertensives, renin-angiotensin-aldosterone system (RAAS) inhibitors, statins, phosphate binders and potentially inappropriate prescribing according to prevailing guidelines was assessed using prescribing quality indicators. Χ2 or Fisher’s exact tests were used to test for differences in prescribing quality.ResultsRAAS inhibitors alone or in combination with diuretics (57% or 52%, respectively) and statins (42%) were prescribed less often than phosphate binders (72%) or antihypertensives (94%) when indicated. Active vitamin D was relatively often prescribed when potentially not indicated (19%). Patients with high CKD stages were less likely to receive RAAS inhibitors but more likely to receive statins when indicated than stage 3 CKD patients. They also received more active vitamin D and erythropoietin-stimulating agents when potentially not indicated.ConclusionsPriority areas for improvement of prescribing in CKD outpatients include potential underprescribing of RAAS inhibitors and statins, and potential overprescribing of active vitamin D. CKD stage should be taken into account when assessing prescribing quality.
Summary
Aim
Quality indicators are used to measure whether healthcare professionals act according to guidelines, but few indicators focus on the quality of pharmacotherapy for diabetes. The aim of ...this study was to develop and validate a set of prescribing quality indicators (PQIs) for type 2 diabetes in primary care, and to apply this set in practice. To take into account the stepwise treatment of chronic disease, clinical action indicators were specifically considered.
Methods
Potential PQIs were derived from clinical practice guidelines and evaluated using the RAND/UCLA Appropriateness Method, a modified Delphi panel. Thereafter, the feasibility of calculating the PQIs was tested in two large Dutch primary care databases including >80 000 diabetes patients in 2012.
Results
32 PQIs focusing on treatment with glucose, lipid, blood pressure and albuminuria lowering drugs, and on vaccination, medication safety and adherence were assessed by ten experts. After the Delphi panel, the final list of twenty PQIs was tested for feasibility. All PQIs definitions were feasible for measuring the quality of medication treatment using these databases. Indicator scores ranged from 18.8% to 90.8% for PQIs focusing on current medication use, clinical action and medication choice, and from 2.1% to 37.2% for PQIs focusing on medication safety.
Discussion and conclusions
Twenty PQIs focusing on treatment with glucose, lipid, blood pressure and albuminuria lowering drugs, and on medication safety in type 2 diabetes were developed, considered valid and operationally feasible. Results showed room for improvement, especially in initiation and intensification of treatment as measured with clinical action indicators.
Summary
Background and objectives
Quality indicators (QIs) can be used for measuring the quality of actions of healthcare providers. This systematic review gives an overview of such QIs measuring ...processes of care for chronic kidney disease (CKD), and identifies the QIs that have content, face, operational and/or predictive validity.
Methods
PubMed and Embase were searched using a strategy combining the terms “quality of care,” “quality indicators” and “chronic kidney disease”. Papers were included if they focused on developing, testing or applying QIs for assessing the quality of care in adult patients with CKD not on renal replacement therapy.
Results
Two hundred and seventy‐three QIs from thirty‐one papers were extracted, including QIs on adequate monitoring of kidney function and vascular risk factors, on indicated treatment, drug safety, adherence and referral to a specialist. The QIs that were considered content, face and operational valid focused on monitoring of glomerular filtration rate, albumin–creatinine ratio, lipid levels and blood pressure, the use of non‐steroidal anti‐inflammatory drugs, nitrofurantoin and biphosphonates in patients with CKD, and QIs on monitoring haemoglobin and treatment with angiotensin‐converting‐enzyme‐inhibitors/angiotensin‐receptor‐II‐blockers in patients with CKD and comorbidities. No QIs were tested for predictive validity. In addition, only two QIs focused on diet and no other QIs focused on lifestyle management.
Conclusions
Based on this review, sufficiently validated QIs can be selected for measuring the quality of CKD care. This review provides insight in QIs that need further validation, and in areas of care where QIs are still lacking.
The authors conducted a systematic literature review to assess whether quality indicators for diabetes care are related to patient outcomes. Twenty-four studies were included that formally tested ...this relationship. Quality indicators focusing on structure or processes of care were included. Descriptive analyses were conducted on the associations found, differentiating for study quality and level of analysis. Structure indicators were mostly tested in studies with weak designs, showing no associations with surrogate outcomes or mixed results. Process indicators focusing on intensification of drug treatment were significantly associated with better surrogate outcomes in three high-quality studies. Process indicators measuring numbers of tests or visits conducted showed mostly negative results in four high-quality studies on surrogate and hard outcomes. Studies performed on different levels of analysis and studies of lower quality gave similar results. For many widely used quality indicators, there is insufficient evidence that they are predictive of better patient outcomes.
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