Approaches to Improve Quality of Care (QoC) for Women and Newborns

An Overview of Systematic Reviews

Rehana A Salam, Zohra Lassi, Jai K Das, Zulfiqar A Bhutta

Aga Khan University Karachi, Pakistan

Background • 287,000 maternal deaths occurred worldwide in 2010 • Only 2 countries accountable for more than a third of global

maternal deaths include – India at 19% (56 000) – Nigeria at 14% (40 000)

• The interventions to improve the QoC is situational, tailored and context specific.

• Systematic reviews have been conducted for the various factors involved in improving the quality of care.

• However, scaling up and sustainability may be difficult to achieve and need careful consideration.

Quality of Health Care Historical roots…

• Literature around quality of healthcare and medical practice started to emerge in the 70s and the concept developed to some extent in the 80s.

• By the 90s, there were models and frameworks being

developed for implementing, assessing and measuring quality care which stemmed from different conceptual understandings

Quality of Health Care its emergence …

•Systems models : quality of care as a product of structure of healthcare services, quality of the process and the quality of the outcome.

Donobedian, 1980

•Perspective models: patients, healthcare providers and healthcare managers perspectives

Ovretveit, 1992 •Characteristic models:

elements and characteristics of the care

Maxwell, 1992, Institute of Medicine

2001

Donabedian A. The Definition of Quality and Approaches to Its Assessment. Arbor A, MI: Health Administration Press. 1980 Ovretveit, J. Health Service Quality: An Introduction to Quality Methods for Health Services, Blackwell, London. 1992

Maxwell RJ. 1992. Dimensions of quality revisited: from thought to action. Qual Health Care. 1992; 1(3):171-7 Institute of Medicine. Crossing the quality Chasm. A new health system for the 21st century. March 2001

Quality of Care The definitions…

Godlee 2009 BMJ

“Clinically effective, safe and a good experience for the patient.”

WHO 2010 “Meeting standard of care that are safe, effective, patient

centered, timely, efficient and equitable”

Quality of Care in Maternal and Child Health…

“Quality of care is the degree to which maternal health services for individuals and populations increase the likelihood of timely and appropriate treatment for the purpose of achieving desired outcomes that are both consistent with current professional knowledge and uphold basic reproductive rights”

Hulton et al. 2000

Framework by Hulton et al. 2000

Previous work • “Improved quality of care may

increase timely and effective use of services, improve psycho-social health outcomes, curtail inappropriate use of resources, harmful technology, eliminate inefficiency, optimize existing inputs and promote following correct procedure”

However • Systematic approach was not used • Focused on institutional delivery

approaches

Previous work

• Included interventions related to continuing education, quality improvement, organization of care, financial or other reimbursement, or regulatory interventions

• Concluded that there are no ‘magic bullets’ or simple solutions for ensuring the quality of health care services. Interventions should be selected or tailored to address the underlying reasons for a failure to deliver effective services.

However: • Limited to low and middle income countries • Did not assess care processes components

QoC Framework approaches to improve the quality

STRUCTURE

District Level Inputs Governance and Accountability Leadership and Supervision Financing Strategy Service Infrastructure-Electronic health records/electronic communication Human Resources-Training/Task shifting Facility Level Inputs Organizational Capacity Appropriate Financing Service Infrastructure-Electronic health records/electronic communication Human Resource-Training Well-performing and Motivated Workforce Interpersonal care / Social support Community level Inputs Financing platforms Human Resource-Training/Task shifting User participation: Community mobilization/ support groups Outreach services/ home visitation or Referral

High Quality Care: -Safe -Timely -Effective -Efficient -Equitable -Responsive

Reduction in: -Death -Disability -Disease -Discomfort -Dissatisfaction

PROCESS OUTCOME

We defined • Quality care is defined using the IOM’s definition of care: safe,

timely, effective, efficient, equitable and responsive to patient’s needs and preferences. Improvements in any of these dimensions of quality will hopefully result in the increased likelihood of desired maternal health outcomes, namely, a reduction in death, disease, disability, discomfort and dissatisfaction with both the care provided and health status.

Objectives

• To systematically assess and summarize information from relevant literature and systematic reviews on the impacts of approaches to improve the quality of care for women and newborns.

• The focus of this review was specifically on approaches that

enable frontline workers (trained health provider either in the community or in a facility) to adopt and implement patient-centered, evidence-based interventions to improve the quality of care during childbirth and immediate postpartum period.

Methods Information on following criteria are extracted: • Characteristics of included reviews

– methods, – participants, – interventions, – Outcomes

• Measurement of treatment effects; • Methodological issues • Gaps

• Quality assessment of included reviews (AMSTAR)

Quality Assessment-AMSTAR • Assessment of Multiple Systematic Reviews (AMSTAR) is a

measurement tool used to assess the methodological quality of systematic reviews while ensuring reliability and construct validity.

• AMSTAR works by isolating 37 critical quality variables for any systematic review, and reducing these to eleven questions a panel can use to assess the quality of any given review.

1. Was an ‘a priori’ design provided? The research question and inclusion criteria should be established before the conduct of the review. 2. Was there duplicate study selection and data extraction? There should be at least two independent data extractors and a consensus procedure for disagreements should be in place. 3. Was there duplicate study selection and data extraction? At least two electronic sources should be searched. The report must include years and databases used (e.g. Central, EMBASE, and MEDLINE). Key words and/or MESH terms must be stated and where feasible the search strategy should be provided. All searches should be supplemented by consulting current contents, reviews, textbooks, specialized registers, or experts in the particular field of study, and by reviewing the references in the studies found. 4. Was the status of publication (i.e. grey literature) used as an inclusion criterion? The authors should state that they searched for reports regardless of their publication type. The authors should state whether or not they excluded any reports (from the systematic review), based on their publication status, language etc. 5. Was a list of studies (included and excluded) provided? A list of included and excluded studies should be provided. 6. Were the characteristics of the included studies provided? In an aggregated form such as a table, data from the original studies should be provided on the participants, interventions and outcomes. The ranges of characteristics in all the studies analyzed e.g. age, race, sex, relevant socioeconomic data, disease status, duration, severity, or other diseases should be reported. 7. Was the scientific quality of the included studies assessed and documented? ‘A priori’ methods of assessment should be provided (e.g., for effectiveness studies if the author(s) chose to include only randomized, double-blind, placebo controlled studies, or allocation concealment as inclusion criteria); for other types of studies alternative items will be relevant.

8. Was the scientific quality of the included studies used appropriately in formulating conclusions? The results of the methodological rigor and scientific quality should be considered in the analysis and the conclusions of the review, and explicitly stated in formulating recommendations. 9. Were the methods used to combine the findings of studies appropriate? For the pooled results, a test should be done to ensure the studies were combinable, to assess their homogeneity (i.e. Chi-squared test for homogeneity, I²). If heterogeneity exists a random effects model should be used and/or the clinical appropriateness of combining should be taken into consideration (i.e. is it sensible to combine?). 10. Was the likelihood of publication bias assessed? An assessment of publication bias should include a combination of graphical aids (e.g., funnel plot, other available tests) and/or statistical tests (e.g., Egger regression test). 11. Was the conflict of interest stated?

Findings

We report the systematic findings of 106 reviews, spread over 12 pre-identified quality of care components based on the conceptual framework. These components fall under the domains of District, Community and Facility level inputs.

District level inputs are generally more sophisticated, technical, and specialized than those available at a community setup, but not as specialized as the facility. These may also include set up and maintenance of health information system, training, and administrative and logistical support in terms of setting up mechanisms for accountability and supervision.

Governance and Accountability • 14 reviews were included with data quality ranged from the score

of 3 to 9.5 on AMSTAR rating scale • Most of the studies are from US, UK or other HIC • Audit and feedback was found to effectively increase immunization

rates; however, the magnitude of the effect is generally modest ranging from 17% absolute decrease to 49% increase.

• It is more effective when targeting test ordering and prevention activities (including mammograms) and when associated with low baseline adherence to recommended care or more intense feedback

• Process of care measures are more positively influenced by feedback than outcome of care measures

• Implementation of audit and feedback mechanisms is influenced by staff coordination, lack of strong evidence base for some topics, poor access to published work and high-quality clinical data and lack of time and motivation.

Leadership and Supervision

• 07 reviews were included with data quality ranged from the score of 5 to 9.5 on AMSTAR rating scale

• Findings are applicable to both LMIC and HIC • Supervision was found to positively influence provider’s practice,

knowledge and awareness and client and provider satisfaction. Its long term effectiveness however, is not evaluated.

• Interventions involving opinion leaders appear to improve compliance [RD: 12%, 95% CI: 6- 14.5%]

• Nursing leadership and supervision have reported improvements in patient satisfaction and reduction of adverse events.

• However, the evidence is inconclusive for mortality rates and

reported complications.

Financial Incentives • 11 reviews were included with data quality ranged from the score of 3

to 9.5 on AMSTAR rating scale • Most of the reviews are pertaining to LMIC • For provider-directed financial strategies, financial incentives may be

effective in improving consultation rates, processes of care, referrals and admission and prescribing costs.

• Small rewards did not show any impact on doctor’s preventive care routines

• Pay-for-performance improved immunization rates • For user-directed financial strategies, significant overall impact on

maternal health service utilization achieved with maternal voucher schemes (RR: 2.97, 95% CI: 2.38-3.71), user fee exemption (RR: 1.57, 95% CI: 1.33-1.85) and community based health insurance (RR: 1.77, 95% CI: 1.29-2.44).

• Maternal vouchers was reported to have the most significant positive increase across all range of outcomes including institutional delivery, skilled birth attendant, complicated delivery, ANC and PNC.

Service Infrastructure: Information system (Electronic Health Records)

• 4 reviews were included with data quality ranged from the score of 3 to 10 on AMSTAR rating scale

• Generalizability of the findings limited to HIC only • Overall there was insufficient evidence to support or refute

the use of electronic retrieval of healthcare information by healthcare providers to improve practice and patient care

• Studies examining physician use of electronic records have found mostly neutral or positive effects on patient satisfaction (3.7%, 95% CI: 2.9-5.2%)

• Some improvement in knowledge about the electronic sources of information was reported among healthcare professionals.

Service Infrastructure: Information system (Electronic Communication)

• 10 reviews were included with data quality ranged from the score of 3 to 10 on AMSTAR rating scale

• Studies are needed to evaluate its effectiveness in LMIC since the generalizability of these findings is mostly limited to HIC

• Significant increase in number of mammograms (Range: 14%-25%) was reported with the use of distance communication.

• Immunization rates also significantly increased (Range: 6.4%-27.2%).

• There is insufficient evidence to support or refute the use of telemedicine technology to support the parents of high-risk newborn infants receiving intensive care.

• Telephone consultation appears to reduce the number of surgery contacts and out-of-hours visits by general practitioners

Community level inputs focuses on resources such as volunteers’ time, local knowledge, and community confidence and trust as channels for delivery of interventions generally related to safe motherhood, nutrition, and simple prevention and treatments. It involves programs based on training and hence task shifting to mid-level health care workers or lay health workers in resource limited settings, providing financial platforms within the community setups, setting up support groups for community mobilization. These programs do not substitute for a health system, but provide a channel for reaching families with information and resources. It also includes home visitation and care by CHW’s.

Outreach Services (Home Visitation and Referrals)

• 14 reviews were included with data quality ranged from the score of 4 to 10 on AMSTAR rating scale

• Studies are needed to evaluate its impact and cost effectiveness in LMIC

• Significant improvement was reported for the outcomes of maternal morbidity (RR: 0.75, 95% CI: 0.61-0.92), neonatal mortality (RR: 0.76 95% CI: 0.68-0.84), perinatal mortality (RR: 0.80, 95% CI: 0.71-0.91), referral (RR: 1.4, 95% CI: 1.19-1.65) and early breast feeding (RR: 1.94, 95% CI: 1.56-2.42).

• Home visitation by CHW’s for appropriate newborn care have reported improved ANC (RR: 1.33, 95% CI: 1.20-1.47), TT coverage: 2 doses (RR: 1.11, 95% CI: 1.04-1.18).

• The likelihood of antenatal hospital admission (RR: 0.79, 95% CI: 0.68-0.92) and caesarean birth (RR: 0.87, 95% CI: 0.78-0.97) was also reported to be significantly reduced.

Human Resource – Task Shifting • 6 reviews were included with data quality ranged from the score of 8 to 10

on AMSTAR rating scale • Findings generalizable to both HIC and LMIC • Care provided by mid-wives have shown significant improvements in

antenatal hospitalization (RR: 0.90, 95% CI: 0.81-0.99), episiotomy (RR: 0.81, 95% CI: 0.77-0.88), instrumental delivery (RR: 0.86, 95% CI: 0.78-0.96), initiation of breast feeding (RR: 1.35, 95% CI: 1.03-1.76) and hospital stay (MD: -2.00,95% CI: -2.15 to -1.85).

• LHW delivered care model has shown significant improvements in immunization uptake (RR: 1.22, 95% CI: 1.10-1.37), breast feeding initiation (RR: 1.36, 95% CI: 1.14-1.61) and child morbidity (RR: 0.86, RR: 0.75-0.99). TB cure rates also improved significantly (RR: 1.22, 95% CI: 1.13-1.31)

• The review reporting the impact of mid-level healthcare workers (MLHW) found few difference in care delivered by midwives compared to GPs/obstetricians

• When nurses were compared with doctors at primary care set-up, nursing care was significantly better for patient satisfaction (RR: 0.28, 95% CI: 0.21-0.34) and recall (RR: 1.34, 95% CI: 1.20-1.49).

Human Resource - Training • 18 reviews were included with data quality ranged from the score of 3 to

11 on AMSTAR rating scale • In-service training to the health personnel including doctors, midwives

and nurses have reported to have significant impacts on maternal mortality (RR: 0.57, 95% CI: 0.36-0.91) and institutional delivery (RR: 2.92, 95% CI: 2.09-4.06).

• In-service training courses specifically directed to improve the management of critically ill newborns also showed significant improvement in performance of initial resuscitation (RR: 2.45, 95% CI: 1.75-3.42) and reduced the frequency of inappropriate and potentially harmful practices (RR: 0.40, 95% CI: 0.13-0.66)

• The review reporting the impacts of training TBA as a part of community based intervention packages showed significant improvement for the outcomes of maternal morbidity (RR: 0.75, 95% CI: 0.61-0.92), neonatal mortality (RR: 0.76 95% CI: 0.68-0.84), perinatal mortality (RR: 0.80, 95% CI: 0.71-0.91), referral (RR: 1.4, 95% CI: 1.19-1.65) and early breast feeding (RR: 1.94, 95% CI: 1.56-2.42)

Community Mobilization-Support Groups

• 2 reviews were included • The data quality ranged from the score of 9.5 to 11 on AMSTAR

rating scale • The packages that involved family members through community

support and advocacy groups and community mobilization and education strategies was reported as one of the most successful community based packages for improving maternal child health

• Impacts of community based intervention packages including support groups showed significant improvement for the outcomes of maternal morbidity (RR: 0.75, 95% CI: 0.61-0.92), neonatal mortality (RR: 0.76 95% CI: 0.68-0.84), perinatal mortality (RR: 0.80, 95% CI: 0.71-0.91), referral (RR: 1.4, 95% CI: 1.19-1.65) and early breast feeding (RR: 1.94, 95% CI: 1.56-2.42).

• The uptake of mammogram increased ranging from 5% to 15% as a result of community intervention including formation of community groups

Facilities provide complex clinical care interventions. Facilities need to provide many forms of support, including advice on which patients to refer, proper post discharge care, and long-term management of chronic conditions. These can also provide important managerial and administrative support to other facilities, serving as gateways for drugs and medical supplies, laboratory testing services, general procurement, data collection from health information systems, and epidemiological surveillance. They are also the vehicle for disseminating technologies by training new staff and providing continuing professional education for existing staff at different facilities.

Well Performing and Motivated Workforce

• 10 reviews were included with data quality ranged from the score of 4 to 10 on AMSTAR rating scale

• Strategies to improve professional practice was reported to significantly improve the desired practice (RR: 1.52, 95% CI: 1.27- 1.82).

• Stress management training intervention have reported to significantly reduce job stress (MD: -6.00, 95% CI: -8.16- -3.84).

• Management intervention improved job satisfaction -0.63 (-1.23- -0.03) but failed to show impact on absenteeism

• Lack of data to evaluate the effectiveness of structural and cultural changes on work force performance.

• Impact of exit interviews is also one of the fields for future research

Interpersonal Care and Social Support • Five reviews were included. None of the reviews analyzed data

from LMIC. • Programs offering additional support during pregnancy were

found to decrease the risk of antenatal hospital admission (RR: 0.79, 95% CI: 0.68-0.92) and caesarean birth (RR: 0.87, 95% CI: 0.78-0.97).

• It did not show any impact on pregnancy outcomes like low birth weight or preterm baby.

• Continuous support during labor was found to significantly increase spontaneous vaginal birth (RR: 1.08, 95% CI: 1.04-1.12), reduce intrapartum analgesia (RR: 0.90; 95% CI: 0.84-0.97), dissatisfaction (RR: 0.69; 95% CI: 0.59-0.79), caesarean delivery (RR: 0.79; 95% CI: 0.67-0.92), regional analgesia (RR: 0.93, 95% CI: 0.88-0.99) and baby with a low 5-minute Apgar score (RR: 0.70, 95% CI: 0.50-0.96).

Safety Culture • 5 reviews were included with data quality ranged from the score

of 1.5 to 8.5 on AMSTAR rating scale • Generalizability of the findings limited to HIC • Influenza vaccination among health care workers reduces mean

no. of working days lost (0.08, 95 % CI: 0.19 to 0.02) and days with influenza like illness (0.12, 95% CI: 0.3 to 0.06).

• The risk of influenza like illness however remained insignificant (RR: 1.14, 95 % CI: 0.15 – 8.52).

• The programmes targeting to increase the uptake of influenza vaccination among healthcare workers reported an increase of 5%–45%.

• It was also reported to be cost saving in the best case (£12/vaccine).

• Pharmacist-led interventions have shown significant impact on reducing hospital admissions (RR: 0.64, 95% CI: 0.43-0.96).

Staffing Model • 6 reviews were included • Generalizeability limited to HIC • The introduction of team midwifery (versus standard care) was

found to reduce medical procedures in labour and resulted in a shorter length of stay without compromising maternal or perinatal safety.

• The addition of specialist nurses to nursing staff resulted in significant reduction in length of stay (1.35 lower, 95% CI: 1.92-0.78 lower).

• Increasing 1 RN FTE/patient day was reported to significantly reduce in-hospital related mortality (RR: 0.92, 95% CI: 0.90-0.94), failure to rescue (RR: 0.91, 95% CI: 0.89-0.94) and length of stay (mean: -0.25, SD: 0.02).

• Some positive impacts of inter-professional collaboration on healthcare processes and outcomes was reported based on small number of studies and sample sizes.

Recommendations-District Level • User directed financial strategies have potential to improve

service utilization • Audit and feedback was found to effectively increase

immunization rates for universally recommended childhood or adult immunization

• Supervision was found to positively influence provider’s practice, knowledge and awareness and client and provider satisfaction

• Interventions involving opinion leaders appear to improve compliance

Recommendations-Community Level

• Packaged care involving outreach, referral, community mobilization and training have shown improvements in maternal and child health outcomes

• Midwife and LHW delivered care have shown significant improvements in maternal and newborn health outcomes

Recommendations-Facility Level

• In-service training and specialty teams have conclusive benefits in improving the maternal health outcomes.

• Support during pregnancy have shown to improve antenatal hospitalization and caesarean delivery

• Strategies to improve professional practice significantly improve the desired practice

Way Forward… • Genralizability of the findings from a few components like social support,

electronic health records and safety culture are limited to HIC only. Hence there is a need to conduct research in LMIC in these domains.

• Furthermore, the findings from generic components of leadership/supervision, health information systems and staffing models were found to be limited on a range of outcomes and not reporting MNCH specific outcomes.

• Another aspect for future research is to fill information gaps on equity and cost effectiveness. Cost-effectiveness is a priority area for future research and researchers should facilitate cost-effectiveness meta-analysis by collecting and reporting cost data in a standardized format.

• There is still a lack of qualitative data describing individual components of the intervention for reproducibility.

• Further evidences are now needed to evaluate the best possible combination of the strategies tailored to the need of the area of implementation.

Thank You!