Health Care Disparities
Effect of Performance Incentives on Hospital Disparities
This longitudinal study sought to determine whether public reporting and pay-for-performance incentives worsen existing disparities between safety net and non–safety net hospitals. Specifically, it assessed the relationship between performance and percentage of patients covered by Medicaid from 2004 to 2006 at 3,665 hospitals. The authors found that hospitals with high percentages of Medicaid patients had worse performance in 2004 and significantly smaller improvements in performance over time for acute myocardial infarction, heart failure, and pneumonia than those with low percentages of Medicaid patients. Further, a simulation model suggested that these low-performing hospitals were more likely to incur financial penalties and less likely to receive bonuses. R. M. Werner et al. (2008) Comparison of Change in Quality of Care between Safety-Net and Non–Safety-Net Hospitals. Journal of the American Medical Association 299, 2180–2187.
Quality Tools in Practice
Do Collaboratives Improve Quality?
For this study, two reviewers systematically examined 72 articles, identified using Medline, Embase, PsycINFO, CINAHL, and Cochrane databases, to evaluate the effectiveness of quality improvement collaboratives in improving care. The authors found the evidence underlying quality improvement collaboratives suggests that they "may have only modest effects on outcomes at best." Because collaboratives play a key role in strategies to accelerate improvement, "further knowledge of the basic components effectiveness, cost effectiveness, and success factors is crucial to determine the value of quality improvement collaboratives," the authors conclude. L. M. T. Schouten et al. (2008) Evidence for the Impact of Quality Improvement Collaboratives: Systematic Review. BMJ 336, 1491–1494.
Collaboratives' Effects Are Hard to Measure
This editorial reviews the article by Schouten and colleagues, which found limited evidence supporting the effectiveness of quality improvement collaboratives. Yet, collaboratives are one of the most popular methods for organizing improvement efforts at hospitals and ambulatory practices worldwide, and "have improved care and saved many lives at participating hospitals," writes the author. He notes that these positive effects might have been missed, possibly due to the limitations of the studies or the inability of traditional biomedical research methods to sufficiently evaluate quality improvement collaboratives. P. K. Lindenauer (2008) Effects of Quality Improvement Collaboratives Are Difficult to Measure Using Traditional Biomedical Research Methods. BMJ 336, 1448–1449.
Intervention's Ability to Improve Sepsis Care Limited
This study assessed whether a national educational program improved physician and nursing staff's ability to recognize and treat severe sepsis and septic shock. Staff were trained to complete two treatment bundles: a resuscitation bundle, with six tasks to begin immediately and be completed within six hours, and a management bundle, with four tasks to be completed within 24 hours. The intervention decreased patients' risk of hospital mortality and improved compliance with processes of care for both the sepsis resuscitation and management bundles. Long-term follow-up showed that the improvement in the resuscitation bundle lapsed within one year, though sepsis management and gains in mortality held over time. R. Ferrer et al. (2008) Improvement in Process of Care and Outcome After a Multicenter Severe Sepsis Educational Program in Spain. Journal of the American Medical Association 299, 2294–2303.
Increasing Adherence to Practice Guidelines
A demonstration project sought to determine whether a multicomponent intervention could promote the translation of research findings into primary care practice. Conducted from Jan. 1, 2003, to June 30, 2006 at 99 practice sites, this improvement model used performance reports (audit and feedback), site visits for academic detailing and participatory planning, and network meetings for sharing of best practices to enhance adherence to practice guidelines across eight clinical areas. The project resulted in clinically and statistically significant improvements for 29 of 36 quality measures, suggesting that this approach "can have a robust impact in quality of care for Americans seen in primary care practices," according to the authors. S. Ornstein et al. (2008) Improving the Translation of Research into Primary Care Practice: Results of a National Quality Improvement Demonstration Project. Joint Commission Journal on Quality and Patient Safety 34, 379–390.
Engaging Physicians in Decreasing Overuse
The authors describe a project, designed as a proof of concept for their model to reduce overuse of services, that decreased the overuse of fiberoptic laryngoscopy among otorhinolaryngologists. Based on both the project's success and their prior experience with individual practitioner pay-for-performance, they conclude that judgmental programs, such as the use of an efficiency index to measure physician performance, tend to interfere with quality improvement. "They score but do not support physician work and therefore are perceived by physicians as disempowering," the authors write. The approach they tested, in contrast, identified wasteful practices and engaged physicians in changing them. R. A. Greene et al. (2008) Beyond the Efficiency Index: Finding A Better Way to Reduce Overuse and Increase Efficiency in Physician Care. Health Affairs Web Exclusive, May 20, 2008 w250–w259.
Study: Hospital Mortality More Likely for Patients Managed by Critical Care Physicians
Patients admitted to ICUs are believed to benefit from the care of specially trained critical care physicians, though evidence of this is scant. A retrospective analysis was used to examine the association between critically ill patients' hospital mortality and their management by critical care or non–critical care physicians. This study assessed the outcomes of 101,832 critically ill adults, treated at 123 ICUs in 100 U.S. hospitals, and found that patients receiving critical care management (CCM) were generally sicker, underwent more procedures, and had higher hospital mortality rates than those who did not receive this care. Further, "[a]fter adjustment for severity of illness and propensity score, hospital mortality rates were higher for patients who received CCM than for those who did not," the authors write. They conclude that additional studies are needed to clarify the mechanisms by which these results might occur. M. M. Levy et al. (2008) Association Between Critical Care Physician Management and Patient Mortality in the Intensive Care Unit. Annals of Internal Medicine 148, 801–809.
Health Care System Performance
ACP: National Entity Should Produce Comparative Effectiveness Data
In this article, the American College of Physicians (ACP) argues that cost-effectiveness information is "a necessary complement to comparative clinical effectiveness information for all health care stakeholders." It explores the availability and use of information comparing clinical outcomes and costs, concluding that a national entity needs to be charged with producing comparative effectiveness and cost-effectiveness information. Producing both comparative clinical and cost data is important, according to the ACP, because both factors are critical to making health care resource decisions for all stakeholders. American College of Physicians (2008) Information on Cost-Effectiveness: An Essential Product of a National Comparative Effectiveness Program. Annals of Internal Medicine 148, 956–961.
Evaluating Cost and Clinical Effectiveness
In this editorial, Gail R. Wilensky reviews the American College of Physicians recommendations on clinical comparative effectiveness. While she supports the use of cost-effectiveness information as an element in decision making by physicians, patients, and payers, Wilensky argues that "it is vitally important to keep comparative clinical effectiveness analysis and cost-effectiveness analysis separate from each other." G. R. Wilensky (2008) Cost-Effectiveness Information: Yes, It's Important, but Keep It Separate, Please! Annals of Internal Medicine 148, 967–968.
Quality, Cost, and Coverage
As quality improvement, cost containment, and coverage expansion are intricately interwoven goals, health insurance coverage reforms that fail to address the system's quality and cost problems ultimately will fail, the authors write. They discuss three policy options they believe policymakers should pursue: 1) build the evidence base for better decision making in health care; 2) promote the development of more effective and efficient models of care; and 3) marshal efforts to avert dire health and financial consequences from population health problems, such as obesity. In addition, they discuss steps that Congress and others can take to move in this direction. M. O'Kane et al. (2008) Crossroads in Quality. Health Affairs 27, 749–758.
Patient Safety
Barcoded Medication Administration Could Reduce Errors
While considerable effort has been directed at reducing prescribing errors, none of the proposed solutions targets medication administration errors, which account for 34 percent of adverse drug events. In this commentary, the authors review barcoded medication administration, which uses barcode labeling of medications and patient wristbands to verify medication and patient identification at bedside. Though this approach requires a significant investment in technology, infrastructure, and training, there is growing consensus on its potential safety benefits. "Nurses have long served as the last line of defense against medication errors," the authors conclude. "The health care system must wait no longer to provide them, and all patients, with the systematic safety net that they deserve." D. W. Cescon and E. Etchells (2008) Barcoded Medication Administration: A Last Line of Defense. Journal of the American Medical Association 299, 2200–2202.
Financial Incentives for Quality
Nonpayment for "Preventable Complications"
This commentary reviews the Centers for Medicare and Medicaid Services' policy, effective October 2008, to withhold additional payments to hospitals when Medicare patients develop one of eight "preventable complications." While the authors believe such policies are likely reasonable and just, they argue that to withhold payments, the complications must be important, measurable, and largely preventable. One complication for which "this is undeniably true" is foreign objects inadvertently left in patients after surgery. However, they conclude, "[n]onpayment for complications that are truly not preventable may destroy trust in quality improvement programs, reduce access for patients at-risk for these complications (e.g., obese patients at increased risk for decubitus ulcers, deep venous thrombosis, and infections may be shunned), reduce the frequency of diagnosis after admission, and misinform the public when safety and quality results are publicly reported." P. J. Pronovost et al. (2008) The Wisdom and Justice of Not Paying for "Preventable Complications." Journal of the American Medical Association 299, 2197–2199.
Effect of Performance Incentives on Hospital Disparities
This longitudinal study sought to determine whether public reporting and pay-for-performance incentives worsen existing disparities between safety net and non–safety net hospitals. Specifically, it assessed the relationship between performance and percentage of patients covered by Medicaid from 2004 to 2006 at 3,665 hospitals. The authors found that hospitals with high percentages of Medicaid patients had worse performance in 2004 and significantly smaller improvements in performance over time for acute myocardial infarction, heart failure, and pneumonia than those with low percentages of Medicaid patients. Further, a simulation model suggested that these low-performing hospitals were more likely to incur financial penalties and less likely to receive bonuses. R. M. Werner et al. (2008) Comparison of Change in Quality of Care between Safety-Net and Non–Safety-Net Hospitals. Journal of the American Medical Association 299, 2180–2187.
Quality Tools in Practice
Do Collaboratives Improve Quality?
For this study, two reviewers systematically examined 72 articles, identified using Medline, Embase, PsycINFO, CINAHL, and Cochrane databases, to evaluate the effectiveness of quality improvement collaboratives in improving care. The authors found the evidence underlying quality improvement collaboratives suggests that they "may have only modest effects on outcomes at best." Because collaboratives play a key role in strategies to accelerate improvement, "further knowledge of the basic components effectiveness, cost effectiveness, and success factors is crucial to determine the value of quality improvement collaboratives," the authors conclude. L. M. T. Schouten et al. (2008) Evidence for the Impact of Quality Improvement Collaboratives: Systematic Review. BMJ 336, 1491–1494.
Collaboratives' Effects Are Hard to Measure
This editorial reviews the article by Schouten and colleagues, which found limited evidence supporting the effectiveness of quality improvement collaboratives. Yet, collaboratives are one of the most popular methods for organizing improvement efforts at hospitals and ambulatory practices worldwide, and "have improved care and saved many lives at participating hospitals," writes the author. He notes that these positive effects might have been missed, possibly due to the limitations of the studies or the inability of traditional biomedical research methods to sufficiently evaluate quality improvement collaboratives. P. K. Lindenauer (2008) Effects of Quality Improvement Collaboratives Are Difficult to Measure Using Traditional Biomedical Research Methods. BMJ 336, 1448–1449.
Intervention's Ability to Improve Sepsis Care Limited
This study assessed whether a national educational program improved physician and nursing staff's ability to recognize and treat severe sepsis and septic shock. Staff were trained to complete two treatment bundles: a resuscitation bundle, with six tasks to begin immediately and be completed within six hours, and a management bundle, with four tasks to be completed within 24 hours. The intervention decreased patients' risk of hospital mortality and improved compliance with processes of care for both the sepsis resuscitation and management bundles. Long-term follow-up showed that the improvement in the resuscitation bundle lapsed within one year, though sepsis management and gains in mortality held over time. R. Ferrer et al. (2008) Improvement in Process of Care and Outcome After a Multicenter Severe Sepsis Educational Program in Spain. Journal of the American Medical Association 299, 2294–2303.
Increasing Adherence to Practice Guidelines
A demonstration project sought to determine whether a multicomponent intervention could promote the translation of research findings into primary care practice. Conducted from Jan. 1, 2003, to June 30, 2006 at 99 practice sites, this improvement model used performance reports (audit and feedback), site visits for academic detailing and participatory planning, and network meetings for sharing of best practices to enhance adherence to practice guidelines across eight clinical areas. The project resulted in clinically and statistically significant improvements for 29 of 36 quality measures, suggesting that this approach "can have a robust impact in quality of care for Americans seen in primary care practices," according to the authors. S. Ornstein et al. (2008) Improving the Translation of Research into Primary Care Practice: Results of a National Quality Improvement Demonstration Project. Joint Commission Journal on Quality and Patient Safety 34, 379–390.
Engaging Physicians in Decreasing Overuse
The authors describe a project, designed as a proof of concept for their model to reduce overuse of services, that decreased the overuse of fiberoptic laryngoscopy among otorhinolaryngologists. Based on both the project's success and their prior experience with individual practitioner pay-for-performance, they conclude that judgmental programs, such as the use of an efficiency index to measure physician performance, tend to interfere with quality improvement. "They score but do not support physician work and therefore are perceived by physicians as disempowering," the authors write. The approach they tested, in contrast, identified wasteful practices and engaged physicians in changing them. R. A. Greene et al. (2008) Beyond the Efficiency Index: Finding A Better Way to Reduce Overuse and Increase Efficiency in Physician Care. Health Affairs Web Exclusive, May 20, 2008 w250–w259.
Study: Hospital Mortality More Likely for Patients Managed by Critical Care Physicians
Patients admitted to ICUs are believed to benefit from the care of specially trained critical care physicians, though evidence of this is scant. A retrospective analysis was used to examine the association between critically ill patients' hospital mortality and their management by critical care or non–critical care physicians. This study assessed the outcomes of 101,832 critically ill adults, treated at 123 ICUs in 100 U.S. hospitals, and found that patients receiving critical care management (CCM) were generally sicker, underwent more procedures, and had higher hospital mortality rates than those who did not receive this care. Further, "[a]fter adjustment for severity of illness and propensity score, hospital mortality rates were higher for patients who received CCM than for those who did not," the authors write. They conclude that additional studies are needed to clarify the mechanisms by which these results might occur. M. M. Levy et al. (2008) Association Between Critical Care Physician Management and Patient Mortality in the Intensive Care Unit. Annals of Internal Medicine 148, 801–809.
Health Care System Performance
ACP: National Entity Should Produce Comparative Effectiveness Data
In this article, the American College of Physicians (ACP) argues that cost-effectiveness information is "a necessary complement to comparative clinical effectiveness information for all health care stakeholders." It explores the availability and use of information comparing clinical outcomes and costs, concluding that a national entity needs to be charged with producing comparative effectiveness and cost-effectiveness information. Producing both comparative clinical and cost data is important, according to the ACP, because both factors are critical to making health care resource decisions for all stakeholders. American College of Physicians (2008) Information on Cost-Effectiveness: An Essential Product of a National Comparative Effectiveness Program. Annals of Internal Medicine 148, 956–961.
Evaluating Cost and Clinical Effectiveness
In this editorial, Gail R. Wilensky reviews the American College of Physicians recommendations on clinical comparative effectiveness. While she supports the use of cost-effectiveness information as an element in decision making by physicians, patients, and payers, Wilensky argues that "it is vitally important to keep comparative clinical effectiveness analysis and cost-effectiveness analysis separate from each other." G. R. Wilensky (2008) Cost-Effectiveness Information: Yes, It's Important, but Keep It Separate, Please! Annals of Internal Medicine 148, 967–968.
Quality, Cost, and Coverage
As quality improvement, cost containment, and coverage expansion are intricately interwoven goals, health insurance coverage reforms that fail to address the system's quality and cost problems ultimately will fail, the authors write. They discuss three policy options they believe policymakers should pursue: 1) build the evidence base for better decision making in health care; 2) promote the development of more effective and efficient models of care; and 3) marshal efforts to avert dire health and financial consequences from population health problems, such as obesity. In addition, they discuss steps that Congress and others can take to move in this direction. M. O'Kane et al. (2008) Crossroads in Quality. Health Affairs 27, 749–758.
Patient Safety
Barcoded Medication Administration Could Reduce Errors
While considerable effort has been directed at reducing prescribing errors, none of the proposed solutions targets medication administration errors, which account for 34 percent of adverse drug events. In this commentary, the authors review barcoded medication administration, which uses barcode labeling of medications and patient wristbands to verify medication and patient identification at bedside. Though this approach requires a significant investment in technology, infrastructure, and training, there is growing consensus on its potential safety benefits. "Nurses have long served as the last line of defense against medication errors," the authors conclude. "The health care system must wait no longer to provide them, and all patients, with the systematic safety net that they deserve." D. W. Cescon and E. Etchells (2008) Barcoded Medication Administration: A Last Line of Defense. Journal of the American Medical Association 299, 2200–2202.
Financial Incentives for Quality
Nonpayment for "Preventable Complications"
This commentary reviews the Centers for Medicare and Medicaid Services' policy, effective October 2008, to withhold additional payments to hospitals when Medicare patients develop one of eight "preventable complications." While the authors believe such policies are likely reasonable and just, they argue that to withhold payments, the complications must be important, measurable, and largely preventable. One complication for which "this is undeniably true" is foreign objects inadvertently left in patients after surgery. However, they conclude, "[n]onpayment for complications that are truly not preventable may destroy trust in quality improvement programs, reduce access for patients at-risk for these complications (e.g., obese patients at increased risk for decubitus ulcers, deep venous thrombosis, and infections may be shunned), reduce the frequency of diagnosis after admission, and misinform the public when safety and quality results are publicly reported." P. J. Pronovost et al. (2008) The Wisdom and Justice of Not Paying for "Preventable Complications." Journal of the American Medical Association 299, 2197–2199.
