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.
Hospital Discharge Summaries Lacking
A study of discharge summaries at two academic medical centers found only 25 percent of them mentioned any pending tests and only 13 percent documented all pending tests. The study, which involved a review of records for 668 patients with test results pending, also found only 16 percent of 2,927 tests were mentioned in the summaries. The study suggests discharge summaries, which play a crucial role in communication between hospital-based physicians and outpatient providers, are inadequate to ensure proper management and follow-up of patients. M. C. Were, X. Li, J. Kesterson et al., Adequacy of Hospital Discharge Summaries in Documenting Tests with Pending Results and Outpatient Follow-up Providers, Journal of General Internal Medicine, September 2009 24(9):1002–06.
Toyota Production System Principles Applied to Psychiatric Patient Transfers
A San Francisco psychiatric hospital used Toyota's efficiency improvement techniques to identify sources of error and delay in its patient transfer protocol. The hospital also used the method to design a standardized transfer process that improved access to appointments and patient safety by reducing communication errors. As a result, the time required to both transfer a patient to its outpatient medication management clinics from other inpatient and outpatient services within the hospital and schedule the first appointment was reduced by 74.1 percent in the first year and by an additional 52.7 percent in the next two years. The time elapsed to the first appointment was reduced by 31.2 percent the first year and was stable in the following two years. J. Q. Young and R. M. Wachter, Applying Toyota Production System Principles to a Psychiatric Hospital: Making Transfers Safer and More Timely, Joint Commission Journal on Quality and Safety, September 2009 35(9):439–48.
Impact of Order Set for Community-Acquired Pneumonia Studied
To assess the impact of a standardized order set for community-acquired pneumonia, Baylor Health Care System studied the use of such a set in eight of its acute-care hospitals. The Dallas, Tex.-based health system found in an unadjusted analysis that the order set improved compliance with clinical guidelines and demonstrated reductions in in-hospital mortality, 30-day mortality, and direct costs. However, after risk-adjustment, only the increase in core measure compliance was retained. N. S. Fleming, G. Ogola, and D. J. Ballard, Implementing a Standardized Order Set for Community-Acquired Pneumonia: Impact on Mortality and Cost , Joint Commission Journal on Quality and Patient Safety, August 2009 35(8):414–21.
Adherence to Treatment Lower When Physicians Communicate Poorly
A meta-analysis of published literature documenting the impact of physician-patient communication on patient adherence to treatment found there is a 19 percent higher risk of non-adherence among patients whose physician communicates poorly compared with patients whose physician communicates well. The researchers, who examined literature published between 1949 and August 2008, also found that training physicians in communication skills leads to significant improvements in patient adherence. K. B. Haskard Zolnierek and R. M. DiMatteo, Physician Communication and Patient Adherence to Treatment: A Meta-Analysis, Medical Care, August 2009 47(8):826–34.
Quality Improvement Initiatives, Professional Satisfaction Linked
A survey of 1,887 randomly selected physicians in Massachusetts found that physicians in practices with quality improvement activities experienced significantly less isolation, stress, and dissatisfaction compared with physicians working in practices that had reported experiencing quality problems. The survey also found a substantial portion of physicians reported moderate to severe problems with isolation (17 percent of respondents), work-life stress (31 percent of respondents), and dissatisfaction (27 percent of respondents). M. A. Quinn, A. Wilcox, J. E. Orav et al., The Relationship Between Perceived Practice Quality and Quality Improvement Activities and Physician Practice Dissatisfaction, Professional Isolation and Work-Life Stress, Medical Care, August 2009 47(8):924–28.
Public Reporting Enhances Performance on Quality Measures in Nursing Homes
A study testing the impact of public reporting on post-acute care in 8,137 nursing homes found that most post-acute care quality measures improved after the launch of Nursing Home Compare. While the quality improvements were statistically significant, the magnitude of the change was small. One measure that did not improve was the rate of potentially preventable rehospitalizations. The researchers found it did not change or worsened slightly after the launch. They concluded that while public reporting may lead to improvement on specific measures, it may not translate into broader quality improvement. To achieve that, policymakers may need to combine public reporting with pay-for-performance initiatives. R. M. Werner, R. T. Konetzka, E. A.Stuart et al., Impact of Public Reporting on Quality of Postacute Care, Health Services Research, August 2009 44(4):1169–86.
Beta-Blockers Lower Mortality for Aneurysm Repair, but Risk-Assessment Is Required
The implementation of the Leapfrog Group's beta-blocker standard in California hospitals led to an estimated 50 percent decrease in mortality following elective abdominal aortic aneurysm repair. Nonetheless, the authors caution that hospitals must continually reexamine the efficacy and the effectiveness of perioperative beta-blocker therapy, given recent research that suggests that for some patients such therapy is associated with a higher risk of stroke and overall mortality. The researchers conclude more stratification of risk is necessary and offer a sample checklist to identify patients who are likely to benefit from the therapy. B. S. Brooke, F. Dominici, M. A. Makary et al., Use of Beta-Blockers During Aortic Aneurysm Repair: Bridging the Gap between Evidence and Effective Practice, Health Affairs, July/August 2009 28(4):1199–09.
Composite Measure More Predictive of Surgical Mortality than Individual Measures
Using data from the Medicare Provider Analysis and Review files, researchers developed a simple measure to predict surgical mortality in the hospital. The composite measure—based on hospital case counts and deaths and tested on six procedures—gives additional weight to the observed mortality rate based on the number of cases and places less weight on such rates when a hospital performs a low number of cases. The composite measure predicted large differences in future risk-adjusted mortality across hospitals, and achieved the most reliable predictions for pancreatic resection. The least predictive composite measure was for coronary artery bypass grafting, although the measure still predicted that future mortality rates for hospitals in the worst quartile were 1.7 times higher than those in the best quartile. J. B. Dimick, D. O. Staiger, O. Baser et al., Composite Measures for Predicting Surgical Mortality in the Hospital, Health Affairs, July/August 2009 28(4):1189–98.
Results of Pay-for-Performance Program in England
A pay-for-performance program in England accelerated improvements in the quality of asthma and diabetes care. Yet, once targets were reached, the pace of improvement in care for patients with these conditions slowed, while the quality of care declined for two conditions not linked to incentives. Continuity of care, a measure of how often patients saw their usual doctor, declined significantly after the program was introduced and remained at a lower level. An unanticipated benefit of the program was a reduction in sociodemographic disparities in the delivery of services. S. M. Campbell, D. Reeves, E. Kontopantelis et al., Effects of Pay for Performance on the Quality of Primary Care in England, New England Journal of Medicine, July 2009 361(4):368–78.
Failure to Document Aortic Dilations in a System with an Advanced EMR
A study of 91 patients at two Veterans Affairs Health System facilities who had aortic dilations newly identified via CT scans found that less than 40 percent of those patients had evidence of the dilations recorded in their medical record within three months of discovery and 18 percent lacked documentation of follow-up care over an average of 3.2 years. In addition, more than 40 percent of patients with new aortic dilations had no follow-up contact with the provider who ordered the initial CT scan. The findings suggest the need for better strategies to ensure test results are acted upon and documented in medical records. J. R. S. Gordon, T. Wahls, R. C. Carlos et al., Failure to Recognize Newly Identified Aortic Dilations in a Health Care System with an Advanced Electronic Medical Record, Annals of Internal Medicine, July 2009 151(1):21–7.
Federal Reporting of Patient Data Necessary, Author Argues
In this commentary, the author argues that private ownership of patient data is not in the best interest of public health or safety and urges the federal government to require hospitals and other medical institutions to report anonymous patient data to a federal agency for public use. The collection and sale of patient data by private companies impedes scientific discovery and puts patients at risk, the author argues. Further, it should not be allowed because patients supply the information and its collection has been financed by the public, via insurance companies, taxes, and other channels. M. Rodwin, The Case for Public Ownership of Patient Data, Journal of the American Medical Association, July 2009 302(1):86–8.
Quality and Spending Not Correlated on a Hospital-Specific Basis, Study Finds
Using Hospital Quality Alliance data to study the association between the quality of care and intensity of spending on end-of-life care on a hospital-specific basis, researchers found the association nil or negative. Indeed, the study demonstrated that hospitals achieved exemplary performance on process-of-care measures for acute myocardial infarction, pneumonia, and heart failure across wide ranges of care intensity. Further, higher- and lower-spending hospitals do not perform uniformly well or poorly on quality indicators. L. Yasaitis, E. S. Fisher, J. S. Skinner et al., Hospital Quality and Intensity of Spending: Is There an Association?, Health Affairs Web Exclusive, May 21, 2009:w566–w572.
