Quality Matters Archive

Quality Matters reported on emerging models and trends in health care delivery reform and interviews with leaders in the field. Please read its successor, Transforming Care.

  • July/August 2009 Issue

Recent Publications of Note

Selected articles on quality improvement from a number of journals, including the American Journal of Medicine, Annals of Internal Medicine, Archives of Pediatric and Adolescent Medicine, BMJ, Health Affairs, Health Services Research, International Journal for Quality in Health Care, Joint Commission Journal on Quality and Safety, Journal of the American Medical Association, Journal of General Internal Medicine, Journal of Patient Safety, Journal of Safety and Quality in Health Care, Medical Care, The Milbank Quarterly, The New England Journal of Medicine, and Pediatrics. The articles are nominated by Editorial Advisory Board members from a preselected list.


Culture, Organizational Support Distinguish Top-Performing Hospitals in Medicare P4P demo
Using performance measure data from October 2004 to September 2005, the authors identified key organizational factors associated with high performance in the Centers for Medicare and Medicaid Services (CMS)/Premier Hospital Quality Incentive Demonstration and found top performers were distinguished by organizational cultures that supported coordination of care, a willingness to try new projects, and a focus on identifying system errors rather than blaming individuals. Also important were the support of nursing staff to increase adherence to quality indicators; use of quality improvement interventions, including clinical pathways; and physician leadership. Educational sessions and data feedback did not distinguish top from bottom performers. E. R. Vina, D. C. Rhew, S. R. Weingarten et al., Relationship Between Organizational Factors and Performance Among Pay-for-Performance HospitalsJournal of General Internal Medicine, July 2009 24(7): 833–40.

Review of Efficiency Measures Identifies Problems with Definition, Reliability
A systematic review of existing health care efficiency measures noted in literature between 1990 and 2008 and in use by measurement product vendors revealed that these measures do not account for differences in quality, and as such, would be more accurately classified as cost-of-care measures. The reviewers also noted, in contrast to quality measures, few existing efficiency measures have been subjected to a rigorous evaluation of their reliability, validity, and sensitivity. They found evidence of reliability or validity reported for six measures (or 2.3 percent of the 265 reviewed). P. S. Hussey, H. de Vries, J. Romley et al., A Systematic Review of Health Care Efficiency Measures, Health Services Research, June 2009 44 (3): 784–805.

Medicare Nonpayment for Hospital Falls May Lead to Restraints and Complications
This perspective argues that Medicare's 2008 decision not to reimburse hospitals for the care of patients who suffer hospital falls and trauma may cause more harm than the falls the initiative is meant to prevent. A review of literature by the authors suggests that, unlike other hospital-acquired conditions that CMS has excluded from payment because they may be reasonably prevented through the use of evidence-based guidelines, only 20 percent of hospital falls can be prevented. The authors warn that hospitals may rely on physical restraints, which are associated with complications such as immobility, functional loss, delirium, agitation, and pressure sores, to reduce the risk of falls. S. K. Inouye, C. J. Brown, and M.E. Tinetti, Medicare Nonpayment, Hospital Falls, and Unintended Consequences, New England Journal of Medicine, June 2009 360(23): 2390–93.

Telemedicine Model Reduces ED Visits for Non-Emergency Problems
Using insurance claims, the authors compared the utilization rates of telemedicine, office care, and emergency department care for patients with access to a Rochester, N.Y., telemedicine service to those without. They found that the overall illness-related utilization rate for office and telemedicine service was 23.5 percent higher for children with access to the service, compared with the control group, but the emergency department utilization was 22.2 percent less. The telemedicine service, known as Health-e-Access, provides care for acute illnesses in children in Rochester-based child care and school sites. K. M. McConnochie, N. E. Wood, N. E. Herendeen et al., Acute Illness Care Patterns Change with Use of TelemedicinePediatrics, June 2009 123(6): e989–e995.

Ending Payments for "Never Events" a Small Step
In this perspective, a member of the Medicare Payment Advisory Commission argues that, while few clinicians and hospitals welcome greater accountability for the financial consequences of flaws in health care services, such as the change in Medicare payment policy that excludes payment for hospital-acquired conditions deemed reasonably preventable, such initiatives resonate loudly with consumers, employers, insurers, and state Medicaid agencies. And while Congress has followed, rather than led, efforts to provide incentives for improving clinical performance, employer, consumer, and labor leaders have begun to collaborate more effectively for increased accountablity. A. Milstein, Ending Extra Payment for "Never Events" — Stronger Incentives for Patients' Safety, New England Journal of Medicine, June 2009 360(23): 2388–90.

Physicians Working in Larger Groups Perform Better on Patient Experience Measures
The authors examined the extent to which medical group and market factors are related to individual primary care physician (PCP) performance on patient experience measures by using survey data on 2,099 adult primary care physicians in medical groups across California and interviews with medical group directors. They found that physicians from integrated medical groups had better performance on communication and care coordination measures and that physicians belonging to medical groups with greater numbers of PCPs performed better on several patient experience measures. Greater emphasis on productivity and efficiency criteria in individual physician financial incentive formulae was associated with worse access to care. H. P. Rodriguez, T. von Glahn, W. H. Rogers et al., Organizational and Market Influences on Physician Performance on Patient Experience Measures, Health Services Research, June 2009 44(3): 880–901.

Study: Medicare P4P Demo Had Little Impact on Value of Care Purchased
This retrospective cohort analysis of 11.2 million hospital admissions, from 6.7 million patients with principal diagnoses of acute myocardial infarction (AMI), heart failure, pneumonia, or a coronary-artery bypass grafting (CABG) procedures from 3,570 acute care hospitals between 2000 and 2006, examined the effects of the CMS/Premier Hospital Quality Incentive Demonstration. The analysis found no evidence that the demonstration had a significant effect on risk-adjusted 30-day mortality rates or risk-adjusted 60-day costs of care for AMI, heart failure, pneumonia, or CABG; it found weak evidence that the program increased risk-adjusted outlier classification(the payment Medicare makes for extremely costly cases) for heart failure and pneumonia. The authors suggest that, by not reducing mortality or cost growth, the demonstration had little impact on the value of inpatient care purchased by Medicare. A. Ryan, Effects of the Premier Hospital Quality Incentive Demonstration on Medicare Patient Mortality and Cost, Health Services Research, June 2009 44(3): 821–42.

Pros and Cons of Denying Payment for Catheter-Associated UTIs
The authors of this perspective examine the preventability of catheter-associated urinary tract infection (UTI), a common and potentially preventable complication of hospitalization for which hospitals no longer receive additional payment from CMS. They also assess the possible consequences of this change and provide guidance to hospital administrators and clinicians. While the authors conclude the change may do more good than harm by encouraging hospitals to minimize the unnecessary placement of indwelling catheters and facilitating their prompt removal, they warn the payment change also may encourage unnecessary screening of urine cultures and antibiotic treatment of asymptomatic bacteriuria. S. Saint, J. Meddings, D. Calfee et al., Catheter-Associated Urinary Tract Infection and the Medicare Rule Changes, Annals of Internal Medicine, June 2009 150(12): 877–84.

Patient Preference Has Little Influence on Regional Variation in Utilization
After comparing Medicare claims data from 2004 and 2005 with the results of a survey of 4,000 Medicare patients, the authors found that patient preferences for immediate or specialty care are associated with higher utilization of health care services on an individual level, but that the distribution of such preferences across regions appears so similar that such preferences have only a minor influence on aggregate regional usage patterns. Regional variations in utilization are more likely the consequence of health care system characteristics, such as supply of specialists, intensive care beds, and medical resources, rather than patient demand, the authors note. D. L. Anthony, M. B. Herndon, P. M. Gallagher et al., How Much Do Patients' Preferences Contribute to Resource Use? Health Affairs, May/June 2009 28(3): 864–73.

For AMI and CHF, Lower-Cost Care Associated with Marginally Lower Quality
Using Hospital Quality Alliance data on 3,794 U.S. hospitals, the authors compared condition-specific costs with process measures and mortality rates and found that, on average, hospitals with lower costs for acute myocardial infarction (AMI) and congestive heart failure (CHF) had marginally lower quality of care for those conditions, although the magnitude of this association was small. The researchers found no relationship between risk-adjusted hospital costs and performance on measures of pneumonia care. They did not find a relationship between the cost of care and mortality rates for these conditions, but did find that hospitals with low risk-adjusted costs were more likely to be for-profit, treat more Medicare patients, and employ fewer nurses, compared with hospitals with higher costs. A. K. Jha, E.J. Orav, A. Dobson et al., Measuring Efficiency: The Association of Hospital Costs and Quality of Care, Health Affairs, May/June 2009 28 (3): 897–906.

Quality More Important than Volume in Determining Coronary Bypass Surgery Outcomes
The authors studied 81,289 patients who had undergone coronary bypass surgery in 164 U.S. hospitals to determine how volume and differences in quality of care affect outcomes and found that maximizing adherence to quality measures is associated with improved mortality rates, independent of hospital or surgeon volume, and that consistent performance on measures of quality seems to be more important than the volume of surgery. A. D. Auerbach, J. F. Hilton, J. Maselli et al., Shop for Quality or Volume? Volume, Quality, and Outcomes of Coronary Artery Bypass SurgeryAnnals of Internal Medicine, May 2009 150 (10): 696–704.

Holding Medicare Advantage Plans Accountable for Quality and Cost
This perspective recommends the Obama Administration and Congress hold health plans accountable for the quality and cost of care they provide to Medicare beneficiaries by requiring plans to provide encounter-level data on the content and cost of services; defining quality improvement goals and measuring success in achieving them; encouraging partnerships between the health plans and their providers; and demonstrating that the plans have implemented processes for end-of-life care that improve physician-patient communication and ensure patient preferences are honored. To hold health plans accountable for their performance, CMS will need additional resources and a mandate from Congress, the author notes. R. Kronick, Medicare and HMOs — The Search for Accountability, New England Journal of Medicine, May 2009 360(20): 2048–50.


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