Indicatoren

Introduction

Quality and transparency are important subjects in the organisation of healthcare in 2017. Thus indicators are developed parallel to guidelines to measure quality of healthcare. The Radiological Society of the Netherlands expects that this set of indicators will stimulate professional conduct in radiology, and other medical specialities involved in implementing the guideline Safe Use of Contrast Media, Part 1, to ultimately improve patient care.

The goal of the indicator set is to measure the implementation of the guideline Safe Use of Contrast Media, Part 1 in hospitals.

Types of indicators

Indicators are measurable elements of healthcare that provide information about the quality of the healthcare delivered (Lawrence, 1997). An indicator is a tool for measuring quality. Defining an indicator is the operationalisation of what you want to measure. Information needs to be obtained to use an indicator, and a calculation is performed based on this information.

There are three types of indicators: input indicators, process indicators and outcome indicators (Donabedian, 1980). Input indicators provide information about (organisational) conditions within which healthcare is provided. An example of an input indicator is “the presence of a stroke unit in a hospital”. Process indicators provide information about proceedings within a healthcare process. A characteristic of process indicators is that they can be influenced directly: they measure how often something had been done. An example of a process indicator is the percentage of patients with diabetes that receive a yearly ophthalmological examination. Outcome indicators provide information about the outcome of healthcare processes, measured at the patient level. Outcome indicators are often dependent on many factors, and can therefore not be linked directly to quality of patient care. An example of an outcome indicator is the percentage of patients with postoperative infections after a cholecystectomy.

Methods

The guideline working group: Safe use of contrast media part 1, has made a selection of recommendations during several meetings. The recommendations were selected by how they influenced the improvement of quality of healthcare. Afterwards, indicators were defined based on the selected recommendations. The indicators were presented for peer review, together with the rest of the guideline, to all scientific societies and other stake holders involved in the development of the guideline. After revision, the indicators were presented for authorization, together with the rest of the guideline.

Results

This is a set of indicators made by and for medical specialists involved in the treatment of patients who receive intravascular iodine-containing contrast medium. The working group has selected subjects that are most relevant, in the opinion of the working group, to promote implementation of the guideline. These subjects are directly linked to the recommendations of the guideline Safe use of contrast media – part 1. Furthermore, the indicators can be directly or indirectly influenced by the healthcare providers. Moreover, the indicators should be able to detect differences between hospitals. A mix of indicators has been chosen, on different quality domains that are valid as a measurement for quality of healthcare. The chosen indicators are reliable and valid.

Overview of indicators

Three indicators were developed, one input indicator and two process indicators.

	Indicator	Type
1	Is there an overall hospital -wide protocol or process-agreement on how prevention of PC-AKI is organized for patients with intravascular iodine-containing contrast medium administration?	input
2	Percentage of patients who receive hydration during CT with iodine-containing CM, from all patients with an eGFR<30ml/min/1.73m² who receive a CT with iv iodine-containing CM.	process
3	Percentage of patients who had an eGFR measurement 3-7 days after CT with iv CM, from all patients with an eGFR<30ml/min/1.73m² who received a CT with iodine-containing CM and were hydrated preventively.	process

CM: contrast medium; CT: computed tomography; eGFR: estimated Glomerular Filtration Ratio; IV: intravascular; PC-AKI: post-contrast acute kidney injury

The indicators are described in the paragraphs below.

Factsheets of indicators

Hospital-wide protocol availability about prevention of PC-AKI

1. Hospital-wide protocols about prevention of PC-AKI
Operationalisation	Is there an overall hospital -wide protocol or process-agreement on how prevention of PC-AKI is organized for patients with intravascular iodine-containing contrast medium administration available?
Numerator	Not applicable
Denominator	Not applicable
Type of indicator	Input
In- and exclusion criteria	Inclusion A hospital-wide protocol, that applies to all departments of the hospital, for the prevention of iv and ia contrast administration
Quality domain	Safety and effectivity
Measuring frequency	Once a year
Report year	2018
Frequency of report	Once a year

Explanation

Background and variation in healthcare

The goal of this indicator is to stimulate hospitals to make hospital-wide agreements and protocols for the prevention of PC-AKI, (e.g. hydration) for patients that receive intravascular iodine-containing CM. In current clinical practice some hospitals have separate protocols in different departments (Radiology and Cardiology, for example), so patients may receive different hydration schemes.

Definitions

PC-AKI: post contrast acute kidney injury – see introduction and definitions chapters of the guideline.

Iv: intravascular – see introduction and definitions chapters of the guideline.

Practical implications

This is an input indicator that can be answered once a year by “yes” or “no” per hospital. It takes several minutes to register this indicator. The working group believes that the burden of registration outweighs the potential quality improvement that can be achieved by this indicator.

Potential confounders

The working group does not expect that case-mix or bias might occur while measuring this input indicator.

Potential unwanted effects

The working group does not expect that unwanted effects might occur while measuring this input indicator.

Percentage of patients that undergo a CT-scan with iodine-containing CM and are hydrated correctly

2. Percentage of patients that undergo a CT-scan with iodine-containing CM and is hydrated correctly
Operationalisation	Percentage of patients who receive hydration during CT with intravascular iodine-containing CM, from all patients with an eGFR <30ml/min/1.73m² who receive a CT with iv iodine-containing CM.
Numerator	Number of patients with an eGFR <30ml/min/1.73m² who receive preventive hydration during CT with intravascular iodine-containing CM
Denominator	All patients with an eGFR <30ml/min/1.73m² who receive a CT with intravascular iodine-containing CM
Type of indicator	Process indicator
In- and exclusion criteria	Inclusion: -patients for whom a CT-scan with iodine-containing intravascular CM is indicated -eGFR<30 ml/min/1.73m² Exclusion: -patients with acute life-threatening conditions, when there is no time to perform an eGFR measurement prior to CM administration. This should be recorded in the patient file. -patients who refused an eGFR measurement or preventive hydration. This should be recorded in the patient file. -dialysis patients without rest diuresis.
Quality domain	Safety and effectivity
Measuring frequency	Once per 3 months
Report year	2018
Frequency of report	Once per year

Explanation

Background and variation in healthcare

The goal of this indicator is to measure whether all patients who receive a CT-scan with iodine-containing iv CM and in whom preventive hydration is indicated, actually receive this hydration in a correct fashion.

Definitions

PC-AKI: post contrast acute kidney injury – see introduction and definitions chapters of the guideline.

Iv: intravascular – see introduction and definitions chapters of the guideline.

Practical implications

The data for this indicator can be extracted from the electronical patient files. The working group believes that the burden of registration outweighs the potential quality improvement that can be achieved by this indicator.

Potential confounders

The working group does not expect that case-mix or bias might occur while measuring this input indicator.

Potential unwanted effects

The working group does not expect that unwanted effects might occur while measuring this input indicator.

Post-contrast kidney function check in all patients who received hydration

3. Post-contrast kidney function check in all patients who received hydration prior to CT-scan
Operationalisation	Percentage of patients who were checked by an eGFR measurement 3-7 days after CT with iv CM, from all patients with an eGFR<30ml/min/1.73m² who received a CT with intravascular iodine-containing CM and were hydrated preventively.
Numerator	Number of patients with an eGFR <30cml/min/1.73m² who were checked by an eGFR measurement 3-7 days after preventive hydration for CT-scan with intravascular iodine-containing CM
Denominator	All patients with an eGFR <30cml/min/1.73m² who receive preventive hydration for CT-scan with intravascular iodine-containing CM
Type of indicator	Process indicator
In- and exclusion criteria	Inclusion: -patients in whom a CT-scan with iodine-containing intravascular CM is indicated -eGFR<30 ml/min/1.73m² Exclusion: -patients with acute life-threatening conditions, when there is no time to perform an eGFR measurement prior to CM administration. This should be recorded in the patient file. -patients who refused an eGFR measurement or preventive hydration. This should be recorded in the patient file. -dialysis patients without rest diuresis
Quality domain	Safety and effectivity
Measuring frequency	Once per 3 months
Report year	2018
Frequency of report	Once per year

Explanation

Background and variation in healthcare

The goal of this indicator is to measure whether all the patients who received preventive hydration receive the correct aftercare.

Definitions

PC-AKI: post contrast acute kidney injury – see introduction and definitions chapters of the guideline.

Iv: intra-vascular – see introduction and definitions chapters of the guideline.

Practical implications

Potential confounders

The working group does not expect that case-mix or bias might occur while measuring this input indicator.

Potential unwanted effects

The working group does not expect that unwanted effects might occur while measuring this input indicator.

References

Donabedian, A. Explorations in Quality Assessment and Monitoring Vol. 1. The Definition of Quality and Approaches to Its Assessment. Ann Arbor, MI: Health Administration Press, 1980