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.

  • April/May 2010 Issue
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Publications of Note

Rate of Nursing Interruptions Documented
A study of 36 registered nurses working in two Midwestern hospitals—one an academic medical center and the other a community-based teaching hospital—found the nurses were interrupted while completing a task 10 times per hour, or once every six minutes. At one hospital, nurses were interrupted once every four-and-a-half minutes; at the other they were interrupted every 13.3 minutes. The study also found that nurses were observed to be multitasking 34 percent of the time. Although the study found no relationship between the interruptions, multitasking, and patient errors, researchers pointed out that work environments for nurses are complex and error prone. B. J. Kalisch and M. Aebersold, Interruptions and Multitasking in Nursing Care, Joint Commission Journal on Quality and Patient Safety, March 2010 36(3):126–32.

Benefits of Team Training Studied in the O.R.
A training program designed to improve teamwork in the operating rooms of a large Southeastern community hospital system was evaluated to determine if it improved patient safety culture and other outcomes. The survey compared trainee reactions, learning, behavior, and results at two hospital campuses—one where staff received training and a control campus where staff received no training. The researchers found the trained group demonstrated significant increases in the quantity and quality of pre-surgical procedure briefings and the use of teamwork behaviors. Increases also were found in staff members' perceptions of the patient safety culture and teamwork attitudes. S. J. Weaver, M. A. Rosen, D. DiazGranados et al., Does Teamwork Improve Performance in the Operating Room? A Multilevel Evaluation, Joint Commission Journal on Quality and Patient Safety, March 2010 36(3):133–42.

Outcomes Improve, Readmissions Decline with Better Cardiac Management
A study of 98,115 adults hospitalized for acute myocardial infarction (AMI) in one of 77 hospitals in Ontario, Canada, between 2000 and 2006 found that hospitals with the highest levels of combined medical and interventional management (measured by the rate of statin prescriptions filled within 30 days of discharge and the rate of cardiac catheterization within 30 days of admission) had lower rates of 30-day mortality, one-year mortality, AMI readmission or death within six months, and major cardiac events within six months, compared with hospitals with lower rates of medical and interventional intensity. The study also found patients admitted to hospitals with the highest rates of appropriate initial emergency department assessments had lower rates of 30-day mortality and one-year mortality. Readmission rates were particularly sensitive to care processes, the researchers found. T. A. Stukel, D. A. Alter, M .J. Schull et al., Association Between Hospital Cardiac Management and Outcomes for Acute Myocardial Infarction Patients, Medical Care, Feb. 2010 48(2):157–65.

Value of Dartmouth Atlas Data for Health Policy Debated
The New England Journal of Medicine published a debate between three authors of the Dartmouth Atlas of Health Care and one of its critics about the appropriateness of using its hospital efficiency measures in setting health care policy. The critic, Peter B. Bach, M.D., M.P.P., an associate attending physician at Memorial Sloan-Kettering Cancer Center, argued that the measures should not be used to identify high-performing hospitals because: 1) the measures attribute care to hospitals over which they may have little control (including the medical consequences of care in nursing homes) and for patients whom they may rarely treat; 2) the measures consider cost and not quality, an essential element of efficiency; and 3) the sample set used—decedents who were enrolled in fee-for-service Medicare—may not accurately reflect a hospital's overall spending pattern. Bach also argued that payments should be based on prospective costs, rather than retrospective costs, as is the case with measures in the Atlas for end-of-life costs. Prospective cost systems will encourage providers to streamline care for all patients, rather than withhold care from the seriously ill, he wrote. Three Atlas authors, Jonathan Skinner, Ph.D., Douglas Staiger, Ph.D., and Elliott S. Fisher, responded by noting that they, too, have concerns about poorly designed incentive programs, especially those that might reward regions—rather than particular physician-hospital networks—for performance. But the authors defended their methodology by explaining: 1) prospective and retrospective measures of costs yield very similar results; and 2) spending measures are modestly but positively associated with one-year mortality from acute myocardial infarction, meaning that, on average, higher-spending hospitals have worse outcomes among patients with acute myocardial infarction. End-of-life costs are an important measure, they argue, because the sample sizes are large and the measure captures common cost factors in hospitals. P. B. Bach, A Map to Bad Policy—Hospital Efficiency Measures in the Dartmouth Atlas, New England Journal of Medicine, Feb. 2010 362(7):569–74 and J. Skinner, D. Staiger, and E .S. Fisher, Looking Back, Moving Forward, New England Journal of Medicine, Feb. 2010 362(7):569–74.

EMR Tool Improves Handoff Accuracy and Consistency at VA
A study of a handoff tool designed with input from clinicians at several Department of Veterans Affairs (VA) medical centers and later embedded in the electronic medical record (EMR) system found it improved the consistency of physician-to-physician information transfer for all handoff content, including code status, medication, and allergy lists. A final version of the software was incorporated into the VA's national EMR program. J. Anderson, D. Shroff, A. Curtis et al., The Veterans Affairs Shift Change Physician-to-Physician Handoff Project, Joint Commission Journal on Quality and Patient Safety, Feb. 2010 36(2):62–71.

Correlation Noted Between Inability to Name Medication and Uncontrolled Blood Pressure
A study of 312 adults with medically treated hypertension from six safety-net clinics in three states found 25.7 percent could not name any antihypertensive medication they took, while 49.5 percent could name one or more of their antihypertensive medications but had discrepancies between the drugs named and those listed in the medical record. Patients who were unable to name any of their antihypertensive medications and patients with such discrepancies were significantly more likely to have uncontrolled blood pressure than patients who accurately named their medications. The authors suggested that performing medication reconciliation at the point of care may provide a means of identifying patients at high risk for inadequate disease control or safety problems. S. D. Persell, S. C. Bailey, J. Tang et al., Medication Reconciliation and Hypertension Control, American Journal of Medicine, Feb. 2010 123(2):182.

Culture of High-Performing Institutions Hard to Replicate
In this commentary, the author outlined the challenges of replicating the success of high-performing medical organizations in medical practices that lack the collaborative organizational culture needed to advance such work. Medical leaders view four elements of strong collaborative cultures as essential: 1) leadership; 2) mission; 3) good measures and feedback of results, including clinical quality indicators; and 4) tools for care coordination, operational system support, and an outstanding clinical information system. Involving physicians and other health care professionals in reorganizing the provision of care and valuing professional autonomy within the context of organizational accountability are also important, the author pointed out. D. Mechanic, Replicating High-Quality Medical Care Organizations, Journal of the American Medical Association, Feb. 2010 303(6):555–6.

Influence of Outpatient Care, Severity of Illness May Be Underestimated in Readmission Rates
A study of readmission rates for premature infants who had been released from one of five neonatal intensive care units at Kaiser Permanente in Northern California found medical and sociodemographic factors—rather than inpatient quality—explained the largest amount of variation in risk-adjusted readmission rates. Illness severity was a powerful predictor of readmissions. Characteristics of outpatient facilities where patients received care after discharge were also associated with variations in readmission rates. The researchers concluded that ignoring outpatient facilities leads to an overstatement of the effect of NICUs on readmissions and ignores a significant cause of variations in readmissions. S. A. Lorch, M. Baiocchi, J. H. Silber et al., The Role of Outpatient Facilities in Explaining Variations in Risk-Adjusted Readmission Rates Between Hospitals, Health Services Research, Feb. 2010 45(1):24–41.

Rates of Rehospitalizations from Nursing Homes High, Variable Across States
Nearly one-quarter of Medicare beneficiaries discharged from the hospital to a skilled nursing facility were readmitted to the hospital within 30 days in 2006, costing Medicare $4.34 billion, according to researchers who used Medicare inpatient claims to calculate rates of rehospitalization from skilled nursing facilities by state. They found the rate of rehospitalization ranged from a low of 15.1 percent in Utah to a high of 28.2 percent in Louisiana. Their analyses found a strong relationship between the number of physician visits and the rate of 30-day rehospitalizations, suggesting that the supply of providers, practice styles, and local area norms may influence some of the rehospitalizations. The researchers suggest policymakers also consider how Medicaid payment policies affect rehospitalization rates. V. Mor, O. Intrator, Z. Feng et al., The Revolving Door of Rehospitalization from Skilled Nursing Facilities, Health Affairs, Jan. 2010 29(1):57–64.

CMS Readmissions Policy May Increase Health Disparities, Authors Suggest
In this commentary, the authors urge the Centers for Medicare and Medicaid Services not to use hospital readmission rates when determining payment policies to avoid creating further inequity in the health care system. Before payment models rely on rehospitalization rates, they must factor in demographic and socioeconomic differences that affect health care utilization and outcomes. If not, they may worsen care coordination and exacerbate health disparities at institutions that treat vulnerable populations, the authors argue. R. Bhalla and G. Kalkut, Could Medicare Readmission Policy Exacerbate Health Care System Inequity?, Annals of Internal Medicine, Jan. 2010 152(2):114–17.

Study: Link Between Hospital Discharge Planning and Readmissions Limited
A study that examined the association between hospital discharge planning and rates of readmission found only a very modest association between performance on patient-reported experiences with discharge planning and readmission rates for patients with congestive heart failure or pneumonia. The study, which relied on data from the Hospital Quality Alliance and Medicare Provider Analysis and Review, found no association between the adequacy of documentation in the chart showing that discharge instructions were provided to patients and readmission rates for patients with congestive heart failure. The authors suggest efforts to collect and publicly report data on discharge planning are unlikely to yield large reductions in unnecessary readmissions. A .K. Jha, E. J. Orav, and A. M. Epstein, Public Reporting of Discharge Planning and Rates of Readmissions, New England Journal of Medicine, Dec. 2009 361(27):2637–45.

Benefits of Telemonitoring of Intensive Care Patients Questioned
Researchers found that the use of remote telemedicine technology to monitor intensive care patients in a large, nonprofit health care system was not associated with a reduction in adjusted hospital or ICU mortality. Nor was it associated with a reduction in rates of complications or lengths of stay. Their statistical analysis suggested telemedicine monitoring did lead to improved survival for more severely ill patients, but with no improvement or worse outcomes in less sick patients. The researchers suggest use of this technology should involve careful monitoring of patient outcomes and costs. E. J. Thomas, J. F. Lucke, L. Wueste et al., Association of Telemedicine for Remote Monitoring of Intensive Care Patients with Mortality, Complications, and Length of Stay, Journal of the American Medical Assn., Dec. 2009 302(24):2671–78.

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