OBJECTIVE: Our aim in this study was to identify the association between place of residence (metropolitan, urban, rural) and guideline-concordant processes of care in the first year of type 2 diabetes management.
METHODS: We conducted a retrospective cohort study of new metformin users between April 2015 and March 2020 in Alberta, Canada. Outcomes were identified as guideline-concordant processes of care through the review of clinical practice guidelines and published literature. Using multivariable logistic regression, the following outcomes were examined by place of residence: dispensation of a statin, angiotensin-converting enzyme inhibitor (ACEi) or angiotensin II receptor blocker (ARB), eye examination, glycated hemoglobin (A1C), cholesterol, and kidney function testing.
RESULTS: Of 60,222 new metformin users, 67% resided in a metropolitan area, 10% in an urban area, and 23% in a rural area. After confounder adjustment, rural residents were less likely to have a statin dispensed (adjusted odds ratio [aOR] 0.83, 95% confidence interval [CI] 0.79 to 0.87) or undergo cholesterol testing (aOR 0.86, 95% CI 0.83 to 0.90) when compared with metropolitan residents. In contrast, rural residents were more likely to receive A1C and kidney function testing (aOR 1.14, 95% CI 1.08 to 1.21 and aOR 1.17, 95% CI 1.11 to 1.24, respectively). ACEi/ARB use and eye examinations were similar across place of residence.
CONCLUSIONS: Processes of care varied by place of residence. Limited cholesterol management in rural areas is concerning because this may lead to increased cardiovascular outcomes.

OBJECTIVE: Develop an efficient, interactive, and instructive checklist document for the management of implanted electronic medical devices in a multimodality radiotherapy clinic.
METHODS: The built-in scripting and interactivity of a popular commercial word processor was used to develop an interactive document that changes the information presented to the user based on drop-down selections. The interactivity and scripting were compatible with the radiation oncology information system (ROIS) which allows the document to be accessible by all team members and serve as a permanent record in a patient\'s electronic chart.
RESULTS: The final interactive document, which was clinically deployed after beta testing with a group consisting of nurses and medical physicists, presents information and action plans to the user based on multiple departmental medical device decision trees that are specific to the combination of device, treatment modality, rhythm-pacing dependence for cardiac devices, and distance from the device to the treatment volume.
CONCLUSIONS: A script-enabled interactive document was developed for a busy multimodality clinic, condensing multiple comprehensive departmental guidelines spanning multiple device types and treatment modalities into a single interactive checklist accessible within the ROIS. Given the wide accessibility of the commercial word processor, this approach could be adopted by other clinics to streamline their own respective workflows.

We examined differences in the timeliness of the initiation of home health care by race and the quality of home health agencies (HHA) among patients with Alzheimer\'s disease and related dementias (ADRD).
Medicare claims and home health assessment data were used for the study cohort: individuals aged ≥65 years with ADRD, and discharged from the hospital. Home health latency was defined as patients receiving home health care after 2 days following hospital discharge.
Of 251,887 patients with ADRD, 57% received home health within 2 days following hospital discharge. Black patients were significantly more likely to experience home health latency (odds ratio [OR] = 1.15, 95% confidence interval [CI] = 1.11-1.19) compared to White patients. Home health latency was significantly higher for Black patients in low-rating HHA (OR = 1.29, 95% CI = 1.22-1.37) compared to White patients in high-rating HHA.
Black patients are more likely to experience a delay in home health care initiation than White patients.

The impact of hospital volume on clinical performance has been investigated by many researchers to date and thought that it is associated with quality of care and outcome for patients with heart failure (HF). This study sought to determine whether annual admissions of HF per cardiologist are associated with process of care, mortality, and readmission.
Among the nationwide registry \'Japanese registry of all cardiac and vascular diseases - diagnostics procedure combination\' data collected from 2012 to 2019, a total of 1 127 113 adult patients with HF and 1046 hospitals were included in the study. Primary outcome was in-hospital mortality, and secondary outcome was 30 day in-hospital mortality and readmission at 30 days and 6 months. Hospital and patient characteristics and process of care measures were also assessed. Mixed-effect logistic regression and Cox proportional-hazards model was used for multivariable analysis, and adjusted odds ratio and hazard ratio were evaluated. Process of care measures had inverse trends for annual admissions of HF per cardiologist (P < 0.01 for all measures: prescription rate of beta-blocker, angiotensin converting enzyme inhibitor or angiotensin II receptor blocker, mineralocorticoid receptor antagonist, and anticoagulant for atrial fibrillation). Adjusted odds ratio for in-hospital mortality was 1.04 (95% confidence interval (CI): 1.04-1.08, P = 0.04) and 30 day in-hospital mortality was 1.05 (95% CI: 1.01-1.09, P = 0.01) for interval of 50 annual admissions of HF per cardiologist. Adjusted hazard ratio for 30 day readmission was 1.05 (95% CI: 1.02-1.08, P < 0.01) and 6 month readmission was 1.07 (95% CI: 1.03-1.11, P < 0.01). Plots of the adjusted odds indicated 300 as the threshold of annual admissions of HF per cardiologist for substantial increase of in-hospital mortality risk.
Our findings demonstrated that annual admissions of HF per cardiologist are associated with worse process of care, mortality, and readmission with the threshold for mortality risk increased, emphasizing the optimal proportion of patients admitted with HF to cardiologist for better clinical performance.

To evaluate the effectiveness of the Enhanced Primary Healthcare (EnPHC) interventions on process of care and intermediate clinical outcomes among type 2 diabetes patients.
This was a quasi-experimental controlled study conducted in 20 intervention and 20 control public primary care clinics in Malaysia from November 2016 to June 2019. Type 2 diabetes patients aged 30 years and above were selected via systematic random sampling. Outcomes include process of care and intermediate clinical outcomes. Difference-in-differences analyses was conducted.
We reviewed 12,017 medical records of patients with type 2 diabetes. Seven process of care measures improved: HbA1c tests (odds ratio (OR) 3.31, 95% CI 2.13, 5.13); lipid test (OR 4.59, 95% CI 2.64, 7.97), LDL (OR 4.33, 95% CI 2.16, 8.70), and urine albumin (OR 1.99, 95% CI 1.12, 3.55) tests; BMI measured (OR 15.80, 95% CI 4.78, 52.24); cardiovascular risk assessment (OR 174.65, 95% CI 16.84, 1810.80); and exercise counselling (OR 1.18, 95% CI 1.04, 1.33). We found no statistically significant changes in intermediate clinical outcomes (i.e. HbA1c, LDL, HDL and BP control).
EnPHC interventions was successful in enhancing the quality of care, in terms of process of care, by changing healthcare providers behaviour.

BACKGROUND: Personalized disease management informed by quantitative risk prediction has the potential to improve patient care and outcomes. The integration of risk prediction into clinical workflow should be informed by the experiences and preferences of stakeholders, and the impact of such integration should be evaluated in prospective comparative studies. The objectives of the IMplementing Predictive Analytics towards efficient chronic obstructive pulmonary disease (COPD) treatments (IMPACT) study are to integrate an exacerbation risk prediction tool into routine care and to determine its impact on prescription appropriateness (primary outcome), medication adherence, quality of life, exacerbation rates, and sex and gender disparities in COPD care (secondary outcomes).
METHODS: IMPACT will be conducted in two phases. Phase 1 will include the systematic and user-centered development of two decision support tools: (1) a decision tool for pulmonologists called the ACCEPT decision intervention (ADI), which combines risk prediction from the previously developed Acute COPD Exacerbation Prediction Tool with treatment algorithms recommended by the Canadian Thoracic Society\'s COPD pharmacotherapy guidelines, and (2) an information pamphlet for COPD patients (patient tool), tailored to their prescribed medication, clinical needs, and lung function. In phase 2, we will conduct a stepped-wedge cluster randomized controlled trial in two outpatient respiratory clinics to evaluate the impact of the decision support tools on quality of care and patient outcomes. Clusters will be practicing pulmonologists (n ≥ 24), who will progressively switch to the intervention over 18 months. At the end of the study, a qualitative process evaluation will be carried out to determine the barriers and enablers of uptake of the tools.
CONCLUSIONS: The IMPACT study coincides with a planned harmonization of electronic health record systems across tertiary care centers in British Columbia, Canada. The harmonization of these systems combined with IMPACT\'s implementation-oriented design and partnership with stakeholders will facilitate integration of the tools into routine care, if the results of the proposed study reveal positive association with improvement in the process and outcomes of clinical care. The process evaluation at the end of the trial will inform subsequent design iterations before largescale implementation.
BACKGROUND: NCT05309356.

Few quality improvement tools specific to patients with persistent or chronic critical illness exist to aid delivery of high-quality care. Using experience-based co-design methods, we sought consensus from key stakeholders on the most important actionable processes of care for inclusion in a quality improvement checklist.
Item generation methods: systematic review, semi-structured interviews (ICU survivors and family) members, touchpoint video creation, and semi-structured interviews (ICU clinicians). Consensus methods: modified online Delphi and a virtual meeting using nominal group technique methods.
We enrolled 138 ICU interprofessional team, patients, and family members. We obtained consensus on a quality improvement checklist comprising 11 core domains: patient and family involvement in decision-making; patient communication; physical comfort and complication prevention; promoting self-care and normalcy; ventilator weaning; physical therapy; swallowing; pharmacotherapy; psychological issues; delirium; and appropriate referrals. An additional 27 actionable processes are contained within 6 core domains that provide more specific direction on the actionable process to be targeted.
Using a highly collaborative and methodologically rigorous process, we generated a quality improvement checklist of actionable processes to improve patient and family-centred care considered important by key stakeholders. Future research is needed to understand optimal implementation strategies and impact on outcomes and experience.

Following the hyperacute phase of spontaneous intracerebral hemorrhage (SICH), the severest form of stroke, pneumonia emerges as the leading cause of morbidity and mortality. Prevention of stroke associated pneumonia (SAP) is fundamental to improve the prognosis of SICH patients.
Identify clinical, sociodemographic and process of care factors associated with occurrence of SAP after SICH in Algarve, southern Portugal.
Observational, retrospective study of community representative consecutive case series of patients with SICH admitted to the sole public hospital in the region. Logistic regression was used to identify predictors of SAP after SICH.
A total of 525 patients were included. The mean age was 71 ( ± 13) years and 64% were men. SAP occurred in 165 (31.5%). Lower Glasgow Coma Scale score (GCS score): ≤ 8 (OR= 2.087; 95% CI= [1.027;4.424]; p = 0.042) and GCS 9-12 (OR= 1.775; 95% CI= [1.030;3.059]; p = 0.039); prolonged emergency room stay (OR= 8.066; 95%CI=[3.082;21.113]; p < 0.001) and hyperactive delirium (OR=2.860; 95% CI= [1.661;4.925]; p < 0.001) increased the likelihood of SAP. Being younger, ≤ 59 years (OR= 0.391; 95% CI= [0.168; 0.911]; p = 0.029) and 60-71 years (OR= 0.389; 95% CI= [0.185; 0.818]; p = 0.013); and having less severe SICH/intracerebral hemorrhage score (ICH score) ≤ 2 (OR=0.601; 95% CI= [0.370; 0.975]; p = 0.039), decreased the risk of SAP.
After SICH, SAP occurs in approximately a third of patients. Non preventable (admission severity, ageing) and potentially preventable (prolonged emergency room stay, hyperactive delirium) determine the occurrence of SAP. Intensification of preventive intervention in high-risk patients, delirium prevention and improvement of the process of care can potentially reduce the occurrence of SAP after SICH.

BACKGROUND: Patients with spontaneous intracerebral hemorrhage (SICH) face the worse functional and vital prognosis among all stroke subtypes. In cases of severe SICH, therapeutic inertia or nihilism complicates meaningful identification of outcome predictors. Therefore, we sought to investigate clinic-radiological and process of care predictors of short-term mortality in patients with mild to moderate SICH.
METHODS: Observational retrospective community representative consecutive case series of patients from Algarve, southern Portugal. Logistic regression was used to identify predictors of short-term (30-day) death.
RESULTS: Mortality was 23.9% (111/464). Most important predictors of death were unconsciousness at admission (OR = 12.392, 95% CI = 3.816-40.241, p < 0.001), hospital arrival ≥ 6 h after stroke onset (OR = 2.842, 95% CI = 1.380-5.852, p =.005), hematoma volume > 30 cc/cm3 (OR = 3.295, 95% CI 0 1.561-6.953, p =.002), intraventricular extension (OR = 2.885, 95% CI = 1.457-5.712, p =.002) and ≥ 24 h in the Emergency Department (OR = 19.675, 95% CI = 3.682-34.125, p =.009). Stroke Unit (SU) admission reduced the likelihood of death (OR = 0.293, 95% CI = 0.137-0.682, p =.002).
CONCLUSIONS: The observed mortality is high. Apart from the traditional clinic-radiological factors, in mild to moderate SICH, process of care related factors have strong impact on mortality. These results highlight the need of continuous improvement of SICH care to improve the prognosis.

OBJECTIVE: Analyse differences in clinical presentation and outcome between bacteraemic pneumococcal community-acquired pneumonia (B-PCAP), and SARS-CoV-2 pneumonia.
METHODS: Observational multicenter study conducted on patients hospitalized for B-PCAP between 2000-2020 and SARS-CoV-2 pneumonia during 2020. We compared 30-day survival, predictors of mortality and intensive care unit (ICU) admission.
RESULTS: We included 663 B-PCAP and 1561 SARS-CoV-2 pneumonia. B-PCAP patients had higher severity, ICU admission and more complications. SARS-CoV-2 pneumonia patients had higher in-hospital mortality (10.8%vs6.8%, p 0.004). Among ICU patients, need for invasive mechanical ventilation (69.7%vs36.2%, p<0.001) and mortality were higher in SARS-CoV-2 pneumonia. In B-PCAP, our predictive model related mortality to systemic complications (hyponatremia, septic shock, neurological complications), lower respiratory reserve or tachypnoea; whereas chest pain and purulent sputum were protective. In SARS-CoV-2, mortality was related to previous liver and cardiac disease, advanced age, altered mental status, tachypnoea, hypoxemia, bilateral involvement, pleural effusion, septic shock, neutrophilia, and high blood urea nitrogen; in contrast, ≥7 days of symptoms was a protective factor. In-hospital mortality occurred earlier in B-PCAP.
CONCLUSIONS: Although B-PCAP was associated with higher severity and ICU rate, SARS-CoV-2 pneumonia-related mortality was higher and occurred later. New prognostic scales and more effective treatments are needed for SARS-CoV-2 pneumonia.