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Background Inadequacy in mental health care in low and middle income countries has been an important contributor to the rising global burden of disease. The treatment gap is salient in resource-poor settings, especially when providing care for conflict-affected forced migrant populations. Primary care is often the only available service option for the majority of forced migrants, and integration of mental health into primary care is a difficult task. The proposed pilot study aims to explore the feasibility of integrating mental health care into primary care by providing training to primary care practitioners serving displaced populations, in order to improve identification, treatment, and referral of patients with common mental disorders via the World Health Organization Mental Health Gap Action Programme (mhGAP). Methods/Design This pilot randomized controlled trial will recruit 86 primary care practitioners (PCP) serving in the Puttalam and Mannar districts of Sri Lanka (with displaced and returning conflict-affected populations). The intervention arm will receive a structured training program based on the mhGAP intervention guide. Primary outcomes will be rates of correct identification, adequate management based on set criteria, and correct referrals of common mental disorders. A qualitative study exploring the attitudes, views, and perspectives of PCP on integrating mental health and primary care will be nested within the pilot study. An economic evaluation will be carried out by gathering service utilization information. Discussion In post-conflict Sri Lanka, an important need exists to provide adequate mental health care to conflict-affected internally displaced persons who are returning to their areas of origin after prolonged displacement. The proposed study will act as a local demonstration project, exploring the feasibility of formulating a larger-scale intervention study in the future, and is envisaged to provide information on engaging PCP, and data on training and evaluation including economic costs, patient recruitment, and acceptance and follow-up rates. The study should provide important information on the WHO mhGAP intervention guide to add to the growing evidence base of its implementation. Trial registration SLCTR/2013/025 .

Patients with advanced chronic kidney disease (CKD) have a high burden of physical and psychosocial symptoms, poor outcomes, and high costs of care. Current paradigms of care for this highly vulnerable population are variable, prognostic and assessment tools are limited, and quality of care, particularly regarding conservative and palliative care, is suboptimal. The KDIGO Controversies Conference on Supportive Care in CKD reviewed the current state of knowledge in order to define a roadmap to guide clinical and research activities focused on improving the outcomes of people living with advanced CKD, including those on dialysis. An international group of multidisciplinary experts in CKD, palliative care, methodology, economics, and education identified the key issues related to palliative care in this population. The conference led to a working plan to address outstanding issues in this arena, and this executive summary serves as an output to guide future work, including the development of globally applicable guidelines.

Abbreviations: CI, confidence interval; HMOs, Health Maintenance Organizations; MDS, Minimum Data Set; RCTs, randomized controlled trials Provenance: Not commissioned; externally peer-reviewed Summary Points * Nursing home residents are a highly vulnerable population, and nursing home care quality has been a persistent focus of public concern. * There is considerable evidence from observational studies that public funding of care delivered in for-profit facilities is inferior to care delivered in public or nonprofit facilities. * The past decade has seen many industrialized countries increasing governmental payment for care of frail seniors in for-profit nursing homes, leading to questions about whether this leads to inferior care. * Many of Bradford Hill's guidelines for causation can be found in published studies supporting a causal link between for-profit ownership and inferior care. * The precautionary principle should be applied when developing policy for this frail and vulnerable population. Introduction Nursing homes, also called residential long-term care facilities or aged care homes, are regulated institutions providing around-the-clock medical and social care to (mainly) older people who are unable to live independently due to physical and/or mental disability. Because of the vulnerability of this population and frequent media reports of scandals across many industrialized countries [1], nursing home care quality has been a persistent focus of public concern.

Objective To assess the impact of a pay for performance incentive on quality of care and outcomes among UK patients with hypertension in primary care.Design Interrupted time series.Setting The Health Improvement Network (THIN) database, United Kingdom.Participants 470 725 patients with hypertension diagnosed between January 2000 and August 2007.Intervention The UK pay for performance incentive (the Quality and Outcomes Framework), which was implemented in April 2004 and included specific targets for general practitioners to show high quality care for patients with hypertension (and other diseases).Main outcome measures Centiles of systolic and diastolic blood pressures over time, rates of blood pressure monitoring, blood pressure control, and treatment intensity at monthly intervals for baseline (48 months) and 36 months after the implementation of pay for performance. Cumulative incidence of major hypertension related outcomes and all cause mortality for subgroups of newly treated (treatment started six months before pay for performance) and treatment experienced (started treatment in year before January 2001) patients to examine different stages of illness.Results After accounting for secular trends, no changes in blood pressure monitoring (level change 0.85, 95% confidence interval −3.04 to 4.74, P=0.669 and trend change −0.01, −0.24 to 0.21, P=0.615), control (−1.19, −2.06 to 1.09, P=0.109 and −0.01, −0.06 to 0.03, P=0.569), or treatment intensity (0.67, −1.27 to 2.81, P=0.412 and 0.02, −0.23 to 0.19, P=0.706) were attributable to pay for performance. Pay for performance had no effect on the cumulative incidence of stroke, myocardial infarction, renal failure, heart failure, or all cause mortality in both treatment experienced and newly treated subgroups.Conclusions Good quality of care for hypertension was stable or improving before pay for performance was introduced. Pay for performance had no discernible effects on processes of care or on hypertension related clinical outcomes. Generous financial incentives, as designed in the UK pay for performance policy, may not be sufficient to improve quality of care and outcomes for hypertension and other common chronic conditions.

In 2004 the U.K. National Health Service introduced a pay-for-performance contract for family practitioners that pays bonuses to physicians based on 146 quality indicators. Seventy-six indicators assess clinical care for chronic diseases, and the remaining indicators focus on organization of care and patient experience. In the first year of the new program, the median reported achievement on the clinical indicators was 83 percent for U.K. family practices. Family doctors' incomes increased by an average of about $40,000. In 2004 the U.K. National Health Service introduced a pay-for-performance contract for family practitioners. In the first year, the median reported achievement on the clinical indicators was 83 percent for U.K. family practices. Family doctors' incomes increased by an average of about $40,000. There is widespread variation in the quality of care in all major health care systems. 1 , 2 In the United Kingdom, where there is a single health care system (the National Health Service), the government has introduced several quality-improvement initiatives since 1998, including national guidelines, a system of “clinical governance” giving clinicians and managers responsibility for delivering high-quality care, and a national inspection system. 3 , 4 There is evidence that these initiatives have substantially improved primary care performance. 5 – 7 In 2004, the National Health Service committed £1.8 billion ($3.2 billion) in additional funding over a period of three years for a new . . .

The Quality Cost Indicator (QCI) model supports value-based health care at the institutional level, by calculating disease-specific health outcomes per unit cost over time. The aim of this study was to adapt the QCI model for specialized burn care (the BC-QCI model) and explore its utilization using real-world data. Burn care outcome indicators were selected through an iterative process with multiple stakeholders. Threshold values were established per outcome indicator and average total healthcare costs were calculated. A cohort of adult burn patients (n = 1449) admitted for at least one day and/or had undergone surgery in Dutch burn centers between 2020 and 2023 was used, with a follow-up period of 12 months. The proportion of patients who achieved textbook outcome (i.e., having achieved all the outcome indicators), the average total costs per patient, and QCI values were calculated. Of all patients, 54% achieved all five outcome indicators (i.e., length of stay, wound infections, other complications, discharge destination, and predicted mortality). The most successful outcome indicator was ‘predicted mortality’ (passed by 99% of the population), the least successful outcome indicator was ‘length of stay’ (62%). The patients who failed to achieve one or more outcome indicators (46%) had significantly higher average total costs compared to the patients who achieved textbook outcome (54%) (€50,134 [€47,810-€52,850] vs. €11,721 [€11,096-€12,429]). The BC-QCI model is a solid foundation to provide insights into the outcomes and costs for specialized burn care at the institutional level.

Background Total joint arthroplasty (TJA) is one of the most widely performed elective procedures; however, there are wide variations in cost and quality among facilities where the procedure is performed. Questions/purposes The purposes of this study were to (1) develop a generalizable clinical care pathway for primary TJA using inputs from clinical, academic, and patient stakeholders; and (2) identify system- and patient-level processes to provide safe, effective, efficient, and patient-centered care for patients undergoing TJA. Methods We used a combination of quantitative and qualitative methods to design a care pathway that spans 14 months beginning with the presurgical office visit and concluding 12 months after discharge. We derived care suggestions from interviews with 16 hospitals selected based on readmission rates, cost, and quality (n = 10) and author opinion (n = 6). A 32-member multistakeholder panel refined the pathway during a 1-day workshop. Participants were selected based on leadership in orthopaedic (n = 4) and anesthesia (n = 1) specialty societies; involvement in organizations specializing in safety and high reliability care (n = 3), lean production/consumption of care (n = 3), and patient experience of care (n = 3); membership in an interdisciplinary care team of a hospital selected for interviewing (n = 8); recent receipt of a TJA (n = 1); and participation in the pathway development team (n = 9). Results The care pathway includes 40 suggested processes to improve care, 37 techniques to reduce waste, and 55 techniques to improve communication. Central themes include standardization and process improvement, interdisciplinary communication and collaboration, and patient/family engagement and education. Selected recommendations include standardizing care protocols and staff roles; aligning information flow with patient and process flow; identifying a role accountable for care delivery and communication; managing patient expectations; and stratifying patients into the most appropriate care level. Conclusions We developed a multidisciplinary clinical care pathway for patients undergoing TJA based on principles of high-value care. The pathway is ready for clinical testing and context-specific adaptation. Level of Evidence Level V, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

External groups requiring measures now include public and private payers, regulators, accreditors and others that certify performance levels for consumers, patients and payers. Although benefits have accrued from the growth in quality measurement, the recent explosion in the number of measures threatens to shift resources from improving quality to cover a plethora of quality-performance metrics that may have a limited impact on the things that patients and payers want and need (ie, better outcomes, better care, and lower per capita costs). Here we propose a policy that quality measurement should be: balanced to meet the need of end users to judge quality and cost performance and the need of providers to continuously improve the quality, outcomes and costs of their services; and parsimonious to measure quality, outcomes and costs with appropriate metrics that are selected based on end-user needs.