The Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City VA Healthcare System, Iowa City, IA 52246, USA.
BMJ Qual Saf. 2012 Aug;21(8):663-9. doi: 10.1136/bmjqs-2011-000243. Epub 2012 Apr 4.
Despite considerable efforts to improve healthcare quality and patient safety, broad measures of patient outcomes show little improvement. Many factors, including limited programme evaluations and understanding of whether quality improvement (QI) efforts are sustained, potentially contribute to the lack of widespread improvements in quality. This study examines whether hospitals participating in a Veterans Health Affairs QI collaborative have made and then sustained improvements.
Separate patient-level risk-adjusted time-series models for two primary outcomes (hospital length of stay (LOS) and rate of discharges before noon) as well as three secondary outcomes (30-day all-cause hospital readmission, in-hospital mortality and 30-day mortality). The models considered 2 years of pre-intervention data, 1 year of data to measure improvements and then 2 years of post-intervention data to see whether improvements were sustained.
Among 130 Veterans Affairs hospitals, 35% and 46% exhibited improvements beyond baseline trends on LOS and discharges before noon, respectively. 60% of improving LOS hospitals exhibited sustained improvements, but only 32% for discharges by noon. Additional subgroup analyses by hospital size and region found a similar performance across most groups.
This quasi-experimental evaluation found lower rates of improvements than normally reported in studies of QI collaboratives. The most striking observation was that a majority of hospitals increased their rates of discharges before noon, but after completing the collaborative their performance declined. Future work needs to qualitatively and quantitatively assess what organisational features distinguish those hospitals that can improve and sustain quality.
尽管为改善医疗保健质量和患者安全做出了相当大的努力，但患者结局的广泛衡量指标几乎没有改善。许多因素，包括有限的方案评估以及对质量改进（QI）工作是否持续的理解，可能导致质量的广泛改善缺乏。本研究考察了参加退伍军人事务部 QI 合作的医院是否取得了进步并得以持续。
分别使用两个主要结局（住院时间（LOS）和中午前出院率）以及三个次要结局（30 天全因住院再入院、住院内死亡率和 30 天死亡率）的患者水平风险调整时间序列模型。该模型考虑了 2 年的干预前数据、1 年的数据来衡量改进，然后是 2 年的干预后数据，以观察改进是否持续。
在 130 家退伍军人事务医院中，分别有 35%和 46%的医院在 LOS 和中午前出院率方面超出了基线趋势的改善。60%的 LOS 改善医院表现出持续的改进，但只有 32%的医院中午前可以出院。按医院规模和地区进行的额外亚组分析发现，大多数群体的表现相似。
这项准实验评估发现，改进的比率低于 QI 合作研究中通常报告的比率。最引人注目的观察结果是，大多数医院增加了中午前的出院率，但在完成合作后，其表现下降。未来的工作需要定性和定量地评估哪些组织特征可以区分那些能够提高和维持质量的医院。
