Organizational quality improvement practices have gained wide acceptance in manufacturing industries over the last several decades. A substantial number of books have been written on Lean and Six Sigma alone, which today are the leading improvement initiatives. The healthcare industry however has been slower to adopt these methods, although anecdotal evidence suggests they are now being gradually diffused throughout hospitals on an increasing basis. Yet, these new practices have been developed substantially without a theoretical foundation (Linderman et al. J Oper Manag 21:193-203, 2003) and the question of industry "fit" is the topic of debate for many physicians and administrators (Kassirer N Engl J Med 339: [1543][1544][1545] 1998). This article provides the descriptive results from our mixed methods research, combining survey questionnaire with semi-structured interviews, that examines implementation of two quality improvement initiatives (Lean and Six Sigma) in a cross-sectional sample of hospitals. We used correlations and non-parametric tests to examine relationships between goal attainment and quality management, and present descriptive findings about reported usage and adoption of quality initiatives. Importantly, we find that the efficacy of quality improvement initiatives in healthcare may be impeded by the lack of goal clarity and measurement. We build on these initial results by offering recommendations to improve results in practice, as well as an agenda for further research of quality initiatives in healthcare. The objectives of our research are to better understand how Lean and Six Sigma fit in the healthcare industry and to explore goal and value attainment from these projects.
OBJECTIVE To evaluate the association between initial diabetic retinopathy (DR) severity/risk of blindness in patients with newly diagnosed DR/good vision in the U.S. RESEARCH DESIGN AND METHODS This retrospective cohort study evaluated adult patients with good vision (20/40 or better) and newly diagnosed DR between 1 January 2013 and 31 December 2017 (index date) in the American Academy of Ophthalmology’s Intelligent Research in Sight (IRIS) Registry. The primary exposure of interest was DR severity at index: mild nonproliferative DR (NPDR), moderate NPDR, severe NPDR, and proliferative DR (PDR). The main outcome measure was development of sustained blindness (SB), defined as study eyes with Snellen visual acuity readings of 20/200 or worse at two separate visits ≥3 months apart that did not improve beyond 20/100. RESULTS Among 53,535 eligible eyes (mean follow-up 662.5 days), 678 (1.3%) eyes developed SB. Eyes with PDR at index represented 10.5% (5,629 of 53,535) of the analysis population but made up 26.5% (180 of 678) of eyes that developed SB. Kaplan-Meier analysis revealed that eyes with moderate NPDR, severe NPDR, and PDR at index were 2.6, 3.6, and 4.0 times more likely, respectively, to develop SB after 2 years of DR diagnosis versus eyes with mild DR at index. In a Cox proportional hazards model adjusted for index characteristics/development of ocular conditions during follow-up, eyes with PDR had an increased risk of developing SB versus eyes with mild NPDR at index (hazard ratio 2.26 [95% CI 2.09−2.45]). CONCLUSIONS In this longitudinal ophthalmologic registry population involving eyes with good vision, more advanced DR at first diagnosis was a significant risk factor for developing SB.
This study provided evidence that certain patient characteristics and healthcare utilization are predictive of readmission. An algorithm with good discriminant ability was developed which could be used to target readmission reduction programs. Physician gender, specialty, and ownership status did not appear to influence the likelihood of readmission.
Purpose To characterize the natural course of diabetic retinopathy (DR) in contemporary clinical practice. Patients and Methods This was a retrospective analysis of US claims data collected between January 1, 2006, and April 30, 2017. Patients aged ≥18 years with continuous medical and prescription insurance coverage for 18 months before DR diagnosis (index date) and for a follow-up period of 5 years were included (N=14,490). The time and risk of progressing to severe nonproliferative DR (NPDR) or proliferative DR (PDR) and of developing diabetic macular edema (DME) were evaluated over 5 years in patients stratified by DR severity at initial diagnosis. Results The estimated probability of progressing to severe NPDR or PDR within 5 years of diagnosis was 17.6% for patients with moderate NPDR versus 5.8% for mild NPDR. The probability of developing DME within 5 years was 62.6%, 44.6%, and 28.4% for patients diagnosed with severe NPDR, moderate NPDR, and PDR, respectively, versus 15.6% for mild NPDR. Among those observed to progress, median time to severe NPDR or PDR was approximately 2.0 years in patients with moderate NPDR, whereas median time to DME was approximately 0.5 years in patients with severe NPDR, 1.3 years in moderate NPDR, and 1.6 years in PDR. Relative to mild NPDR, adjusted hazard ratios (95% confidence interval) for progression to severe NPDR or PDR within 5 years were 3.12 (2.61–3.72) in patients with moderate NPDR, and for incident DME were 5.92 (5.13–6.82), 3.54 (3.22–3.91), and 1.96 (1.80–2.14) in patients with severe NPDR, moderate NPDR, and PDR, respectively. Conclusion The risk of DR progression and DME over 5 years was highest among patients diagnosed with moderate and severe NPDR, respectively. Our findings reinforce the importance of close monitoring for these patients to avoid unobserved disease progression toward PDR and/or DME.
As the use of electronic health records increases, it becomes necessary to address their global impact on nurses' productivity in hospitals. A retrospective cross-sectional study was conducted to explore the impact of electronic health records on nurses' productivity and to examine whether the impacts are moderated through case-mix index or adjusted patient-days. Two sources of data were linked and analyzed for years 2007 and 2008: the American Hospital Association survey and the Centers for Medicare & Medicaid Services data. Almost two-thirds of the respondent hospitals in both years (63.9% in 2007 and 68.4% in 2008) had a high electronic health record index (≥5). Hospitals with higher penetration of electronic health records had more RNs employed (coefficient=0.234, P=.002) compared with hospitals with low penetration of electronic health records, even when controlling for adjusted patient-day volumes. This difference decreased for hospitals with higher case-mix index values. The study findings fail to suggest any financial savings or superior productivity in nurses due to usage of electronic health records.
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