Explanation & Elaboration

18. Conclusions

1. Considers overall practical usefulness of the intervention
2. Suggests implications of this report for further studies of improvement interventions

Example

"After demonstrating the feasibility of DMP [Discharge Medication Program] implementation throughout the 10 pilot institutions and its success in producing high adherence to discharge medication guidelines, IHC [Intermountain Health Care] expanded the program to include all 21 hospitals in the system. The DMP is now a solidly integrated program that continues to produce high rates of adherence to cardiovascular medication guidelines.

. . . Implementation of the DMP within the 10 hospitals required no additional employees. Adherence was tracked by using the existing hospital medical informatics infrastructure, adding only minimal cost to hospital operations. Consequently, we believe that cost was low relative to the numbers of lives potentially saved, especially when compared with recent improvements in cardiovascular care, such as drug-eluting coronary stents.

The comprehensiveness of the DMP is also substantially limited because patients were enrolled only if their principal diagnosis was cardiovascular. For instance, if a cardiovascular patient was admitted to the hospital with some other diagnosis, such as hip fracture, the DMP in our study would not have affected his or her discharge medications. Thus, this DMP could be used to treat even more patients if it were expanded to include everyone admitted with secondary diagnoses of cardiovascular disease.

Our study demonstrates that a relatively simple quality improvement project aimed at enhancing the use of appropriate discharge medications in patients hospitalized with a cardiovascular diagnosis is feasible and can be sustained on a large scale in a multihospital integrated system. Most important, our findings suggest that such a program may have substantial long-term lifesaving benefits across a broad system of integrated hospitals." [42]

Elaboration

The conclusion to a quality improvement paper should summarize the lessons learned from the project and detail the potential next steps for investigation. It should also describe how the successes of the project (if applicable) will be maintained or expanded. In the above example, the authors include the information that their improvement program has been expanded to the other institutions in their hospital system and that improvement is being monitored through rates of adherence to cardiovascular medicine guidelines. This is one example of generalizability within the same organization.

Conclusions may also describe how the local context might translate to other clinical arenas. Reflections as to what might be necessary to sustain the improvement or to test the improvement intervention in another care setting are helpful. Finally, suggestions as to possible next steps are also useful. The authors in this example suggest other patient populations who may benefit from the intervention. The goal of the conclusion is not only to summarize the local implications of the project, but also to provide insights to those readers who are considering the applicability of the presented intervention to their local care setting. Finally, it is useful for authors to consider, "What important questions does this study leave unanswered?" and "What studies would be most useful to answer those questions? Why?"

References

42. Lappe JM, Muhlestein JB, Lappe DL, et al. Improvements in 1-year cardiovascular clinical outcomes associated with a hospital-based discharge medication program. Annals of Internal Medicine. 2004;141(6):446-453.

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