5. Results
5.1 Summary of Results
5.1.2 Article II. Development of quality of care indicators from systematic
5.1.2.1 Search results and characteristics of the reviews
We obtained 303 systematic reviews with the search strategy. After reading their titles and abstracts, we included a total of 48 Cochrane systematic reviews. None of them were excluded due to poor methodological quality. However, 28 reviews were excluded because they did not provide a solid basis for generating a recommendation for or against the intervention. Finally, we drafted 20 clinical recommendations based on high-quality evidence.
5.1.2.2 Construction and validation of indicators
Approximately 75% of the authors of the selected SR responded to our request to review the indicator. In general, they agreed with the indicators proposal and their comments were used to further improve the indicators definition.
Following the advice of expert obstetric consultants, two indicators were removed. One was about the proportion of women with a single pregnancy at risk of preterm delivery treated with a combination of corticosteroids with a thyrotropin-releasing hormone. It was excluded because this intervention is no longer used in clinical practice. The second indicator that was excluded was the proportion of deliveries by caesarean section because the evidence presented was considered to be controversial. We observed that the feedback from the experts in Obstetrics was more objective than the consultation of the review authors, especially with regard to the relevance of the indicator.
5.1.2.3 Indicators
We obtained 18 indicators from 303 systematic reviews (6%), which are shown in Table 6. Eight indicators apply at the time prior to delivery, another eight during delivery, one in the immediate postpartum period and the other in the management of miscarriages.
Initiatives to improve the appropriateness of clinical practice in the hospital setting
85 Results
All the 18 indicators are expressed in proportions and refer to the care process; no structure or result indicators were generated. All but six indicators describe a desirable event, that is, higher values indicate more appropriate care. The full content of one of the 18 indicators (proportion of women with singleton pregnancies and threatened preterm labour who receive corticosteroids) is shown in the Table 2 of Appendix 3.2 as an example.
After the process of generating the indicators, we consulted the Cochrane Library again to verify the status of the SR that were the source of the indicators. All the SR had been updated between 2009 and 2011. Three SR changed their conclusions;
however, none of those changes invalidated the indicators: the first SR, on the use of antibiotics in women with premature rupture of the membranes, concluded that despite the short-term benefits during pregnancy, users should be aware of the unknown long-term effects on new-borns. The second SR, which evaluated the use of antibiotics in prophylaxis during caesarean section, provided a similar warning about the unknown long-term effects in new-borns. The third SR, on active management versus expectant management in the third stage of labour, found potential adverse effects with various uterotonics and concluded that information on benefits and harms should be provided to support an informed choice.
Initiatives to improve the appropriateness of clinical practice in the hospital setting
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Table 6. Indicators based on systematic reviews in Obstetrics.
Indicator Target
population
ICD-9
Codesa Indicator formulab Standardc 1 Proportion of women with
singleton pregnancies and threatened preterm labour (TPL) who receive corticosteroids N: Women who received
corticoids E: Corticoids contraindications 2 Proportion of women who are
treated with calcium channel blockers (CCB) for inhibiting preterm labour N: Women who received
CCB
E: Contraindication to CCB 3 Proportion of women with
threatened preterm labour (TPL) treated with magnesium sulphate
Women with
D: Women who received pharmacological treatment for TPL
≈0
N: Women who received magnesium sulphate E: None
4 Proportion of women with preterm rupture of membranes (PRM) who receive antibiotic treatment N: Women who received
antibiotics E: None 5 Proportion of women with
post-term pregnancy who give birth after 41 weeks of gestation
Women with N: Women with labour
induction
E: Spontaneous labour, non-urgent caesarean delivery
6 Proportion of women with severe pre-eclampsia who were treated with magnesium sulphate
Women with severe preeclampsia
642.5 D: Women with severe pre-eclampsia
≈100 N: Women who received
magnesium sulphate E: Contraindication to magnesium sulphate 7 Proportion of women with
eclampsia treated with magnesium sulphate
Women with eclampsia
642.6 D: Women with eclampsia ≈100 N: Women who received
magnesium sulphate E: Contraindication to magnesium sulphate 8 Proportion of women with term
pregnancies and a breech presentation in which external cephalic version is performed or offered
Women with breech presentation
73.91 D: Breech presentation ≈100 N: Women in whom
cephalic version was performed or offered E: None
9 Proportion of unjustified episiotomies N: Procedures without any
reason documented E: None
Initiatives to improve the appropriateness of clinical practice in the hospital setting
Codesa Indicator formulab Standardc 10 Proportion of women whose
second-degree perineal tear or episiotomy is repaired with continuous suture second-degree perineal tear or episiotomy 11 Proportion of women who are
given an enema during labour
Women in
12 Proportion of women having perineal shaving on admission to the delivery room 13 Proportion of women who are
administered uterotonics in the third stage of labour
Women in N: Women who received
uterotonics
E: Contraindication to uterotonics, patient refusal to receive uterotonics 14 Proportion of women undergoing
caesarean section who receive antibiotic therapy
Women on whom
caesarean was performed
74.XX D: Women who received caesarean
≈100 N: Women who received
antibiotics E: None 15 Proportion of women whose
peritoneum is sutured at caesarean delivery
Women on whom
caesarean was performed
74.XX D: Women who received caesarean
≈0 N: Women for whom
peritoneum was sutured E: None
16 Proportion of health
professionals who use double gloves when attending a woman with a blood-borne disease
Health professionals performing surgical procedures
None D: Health professionals who performed surgical procedures in woman with a blood-borne disease
≈100
N: Health professionals who used double gloves E: None
17 Proportion of Rh-negative women who are given Anti-D within 72 hours after the birth of an positive or
Rh-undetermined baby
Rh-negative pregnant women
None D: Rh-negative women with Rh-positive new-born
≈100 N: Women who received
Anti-D
E: Women with prior Rh sensitisation.
Initiatives to improve the appropriateness of clinical practice in the hospital setting
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Table 6. (Continued)
Indicator Target
population
ICD-9
Codesa Indicator formulab Standardc 18 Proportion of women with
incomplete miscarriage who, if a surgical evacuation of retained products is carried out, undergo a vacuum aspiration
Women with incomplete miscarriage
634.X1 -638.X1
D: Women with incomplete miscarriage
≈100 N: Women in whom
vacuum aspiration was performed
E: Contraindication to vacuum aspiration
a In this column, the value “X” means any number between 0 to 9.
b In this column, (D) Denominator, (N) Numerator, (E) Exclusion criteria.
c Theoretical standards: 100% means a desirable event (higher values indicate appropriate performance) and 0% an undesirable event (lower values indicate inappropriate performance)
5.1.3 Article III. Healthcare Quality Indicators of Peripheral Artery Disease