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.

  • December 2010/January 2011 Issue
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Publications of Note

Residents Outperform Staff Physicians on Some Measures of Outpatient Care
A study designed to compare the quality of care provided by resident and staff physicians provided during hospital-based outpatient visits found that residents outperformed staff on four of 19 process-of-care measures, including angiotensin converting enzyme inhibitor use for congestive heart failure (57.0% vs. 27.6%), diuretic use for hypertension (57.8% vs. 44%), statin use for hyperlipidemia (56.3% vs. 40.4%), and routine blood pressure screening (85.3% vs. 79.6%). Residents and staff performed at similar levels for counseling and on measures capturing inappropriate prescribing or overuse of diagnostic testing. Residents and staff also performed similarly on measures of appropriate prescribing. The study also found resident physicians were more likely than staff physicians to care for younger, non-white, female, urban, and Medicaid-insured patients. L. Zallman, J. Ma, L. Xiao et al., Quality of US Primary Care Delivered by Resident and Staff Physicians, Journal of General Internal Medicine, November 2010 25(11):1193–97.

Use of Checklist Associated with Reduction in Surgical Complications and Mortality
The implementation of a multidisciplinary surgical safety checklist in six hospitals with high standards of care led to a reduction in the number of complications per 100 patients from 27.3 percent to 16. 7 percent. The study, focused on hospitals in the Netherlands, also found the proportion of patients with one or more complications decreased from 15.4 percent to 10.6 percent. In-hospital mortality fell from 1.5 percent to 0.8 percent. The study compared outcomes for 3,670 patients observed before implementation of the checklist with 3,820 patients observed after its implementation. The checklist was designed to improve medication checks, marking of the operative side, and use of post-operative instructions. E. N. de Vries, H. A. Prins, R. M. P. H. Crolla et al., Effect of a Comprehensive Surgical Safety System on Patient Outcomes, New England Journal of Medicine, November 2010 363(20):1928–37.

Use of Fall Prevention Toolkit Significantly Reduces Rate of Falls
The use of a fall prevention toolkit, which combined a fall risk assessment with software-tailored fall prevention interventions, reduced the rate of patient falls per 1,000 patient days to 3.15 in hospital units that used the intervention. This compared with a rate of 4.18 falls per 1,000 patient days in hospital units that did not use the intervention. The study found the toolkit was particularly effective among patients ages 65 years or older. No significant effect was noted in fall-related injuries. The program produced bed posters composed of brief text, patient education handouts, and plans of care, all of which contained patient-specific alerts. P. C. Dykes, D. L. Carroll, A. Hurley et al., Fall Prevention in Acute Care Hospitals: A Randomized Trial, Journal of the American Medical Association, November 2010 304(17):1912–18.

Public Reports of Physician Quality of Care Lacking
A study that examined information from 263 public reports on provider performance from 21 geographic areas found that reports of hospital performance exceed reports of physician performance, that reports on physician performance typically contained measures of chronic illness treatment collected at the medical group level, and that patient experience measures were more readily available in hospital reports than physician reports. J. B. Christianson, K. M. Volmar, J. Alexander et al., A Report Card on Provider Report Cards: Current Status of the Health Care Transparency Movement, Journal of General Internal Medicine, November 2010 25(11):1235–41.

Comparison of CLABSI Rates Complicated by Surveillance Methods
A study designed to assess the institutional variation in performance of traditional central-line associated bloodstream infection (CLABSI) surveillance found that there is significant variation in the application of standard CLABSI surveillance definitions across medical centers. This suggests it may invalid to compare rates across institutions, unless surveillance is performed consistently across them. The study correlated CLABSI rates as determined by infection preventionists with those generated by computer algorithm reference standard, using data from 20 intensive care units across four medical centers. M. Y. Lin, B. Hota, Y. M. Khan et al., Quality of Traditional Surveillance for Public Reporting of Nosocomial Bloodstream Infection Rates, Journal of the American Medical Association, November 2010 304(18):2035–41.

Medicaid Reimbursement Rates Strongly Associated with Influenza Vaccinations Rates for Infants and Toddlers
An analysis of three consecutive National Immunization Surveys found positive, significant associations between state-level Medicaid reimbursement and influenza vaccination rates among poor children. A $10 increase (from $8 per influenza vaccination to $18) was associated with 6.0-, 9.2-, and 6.4-percentage point increases in full vaccination rates among poor children ages 6 to 23 months in 2006, 2007, and 2008, respectively. The study also found that 21.0 percent, 21.3 percent, and 28.9 percent of all U.S. children and 11.7 percent, 11.6 percent, and 18.8 percent of poor children were fully vaccinated in 2006, 2007, and 2008, respectively. B. K. Yoo, A. Berry, M. Kasajima et al., Association Between Medicaid Reimbursement and Child Influenza Vaccination Rates, Pediatrics, November 2010 126(5):e998–e1010.

Correlation Between Surgical Safety and Hospital Volume Varies Across Interventions
A study designed to assess the effect of hospital volume on surgical complications, potentially avoidable reoperations, and deaths at 353 hospitals found that hospitals with more experience in a given intervention had similar reoperation rates, but lower mortality and complication rates. However, the study found that the benefit was limited to heart surgery and a small number of other operations. The authors suggest it may be more efficient to monitor risk-adjusted postoperative outcomes and to investigate facilities with worse-than-expected outcomes than to adopt policies based on minimum volume thresholds. Y. Eggli, P. Halfon, D. Meylan et al., Surgical Safety and Hospital Volume Across a Wide Range of Interventions, Medical Care, November 2010 48(11):962–71.

Prevalence of Value-Based Insurance Design Finds Interest High But Use Lower
A study designed to estimate the prevalence of value-based insurance design plans found that less than 20 percent of employers that had 500 or more employees and responded to the Mercer National Survey of Employer-Sponsored Health Plans reported using such plans for prescription drugs or nondrug treatments. However, 81 percent of employers with 10,000 or more beneficiaries were interested or very interested in implementing such plans within the next five years. The study also noted common structures for value-based insurance design programs, including reducing copayments to encourage patients with specific conditions to make use of available therapies and creating copayment tiers to encourage patients to use lower-cost medications. The authors concluded that more studies are necessary to evaluate these programs’ impact on quality and health care spending. N. K. Choudhry, M. B. Rosenthal, and A. Milstein, Assessing the Evidence for Value-Based Insurance Design, Health Affairs, November 2010 29(11):1988–94.

Hospital Compare Underestimates Mortality Rates in Low-Volume Hospitals, Study Finds
Hospital Compare significantly underestimates average observed death rates in small-volume hospitals, according to a study that examined Medicare claims on 208,157 patients with acute myocardial infarction who were admitted to one of 3,629 acute care hospitals in the U.S. The study found that including hospital volume in the Hospital Compare model significantly improved predictions. Its authors conclude that using volume and other important characteristics may be indicated when using a random effects model to predict outcomes. J. H. Silber, P. R. Rosenbaum, T. J. Brachet et al., The Hospital Compare Mortality Model and the Volume-Outcome Relationship, Health Services Research, October 2010 45(5):1148–67.

Team Training Leads to Lower Surgical Mortality
A study of the Veterans Health Administration’s use of medical team training found the program for operating room personnel reduced annual mortality by 18 percent, compared with a 7 percent decrease among facilities that had not yet participated in the training program. The training program required briefings and debriefings in the operating room and included checklists as an integral part of the process. The training also included two months of preparation, a one-day conference, and one year of quarterly coaching interviews. J. Neily, P. D. Mills, Y. Young-Xu et al., Association Between Implementation of a Medical Team Training Program and Surgical Mortality, Journal of the American Medical Association, October 2010 304(15):1693–1700.

Knee Replacement Outcomes Better and Costs Lower at High-Performance Hospitals
A study of claims data related to knee replacement surgery at 688 hospitals found 62 hospitals failed to meet effectiveness criteria and 210 were identified as inefficient. Analyzing the remaining 416 high-performance hospitals, researchers found the high-performance hospitals had 13.4 percent fewer risk-adjusted adverse outcomes and 9.9 percent lower risk-adjusted total costs than all study hospitals. The authors conclude a payment system based on demonstrated performance could produce sizeable savings without jeopardizing quality. The study examined risk-adjusted mortality, postoperative length-of-stay, costs of routine care, adverse outcome rates, and excess costs of adverse outcomes for total knee replacements performed between 2002 and 2005. M. Pine, D. E. Fry, B. L. Jones et al., Controlling Costs Without Compromising Quality: Paying Hospitals for Total Knee Replacement, Medical Care, October 2010 48(10):862–8.

Patient-Centered Care Linked to Clinical Benefits for AMI
A study designed to test the influence of patient-centered care and quality on outcomes among patients with acute myocardial infarction (AMI) found that patient-centered care was associated with a modestly lower hazard of death over the one-year study period. The study analyzed data from a national sample of 1,858 veterans hospitalized for an initial AMI in a Department of Veterans Affairs medical center during fiscal years 2003 and 2004 for whom data had been compiled on evidence-based treatment and who had also completed a Picker questionnaire assessing the patients’ perceptions of patient-centered care. M. Meterko, S. Wright, H. Lin et al., Mortality Among Patients with Acute Myocardial Infarction: The Influences of Patient-Centered Care and Evidence-Based Medicine, Health Services Research, October 2010 45(5):1188–204.

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