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.

  • June/July 2010 Issue

Publications of Note

Early Physician Follow-Up Lowers 30-day Readmission Risk
A study of Medicare beneficiaries hospitalized for heart failure found that patients who were discharged from hospitals that had higher rates of early outpatient follow-up (within seven days) after discharge had lower risk of 30-day readmission, compared with patients discharged from hospitals with lower rates. The study population included 30,136 patients from 225 hospitals who were discharged home from hospitals that participated in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure and the Get With the Guidelines–Heart Failure quality improvement program from January 1, 2003, through December 31, 2006. The study also found the median percentage of patients who had early follow-up care after discharge from the index hospitalization was 38.2 percent. Patients in the lowest quartile of early follow-up had a 23.3 percent 30-day readmission rate while patients in the top quartile had a readmission rate of 20.9 percent. A. F. Hernandez, M. A. Greiner, G. C. Foranow et al., Relationship Between Early Physician Follow-Up and 30-Day Readmission Among Medicare Beneficiaries Hospitalized for Heart Failure, Journal of the American Medical Association, May 2010 303(17):1716–22.

Accountable Physician Practices Achieve Higher Quality at Lower Cost
Researchers compared the cost and quality of care delivered to Medicare beneficiaries served by two groups of physicians: those who worked in large multispecialty group practices affiliated with the Council of Accountable Physician Practices (CAPP) and those who did not. They found Medicare beneficiaries cared for by CAPP-affiliated physicians received between 5 to 15 percent higher-quality care at a cost that was 3.6 percent lower. The researchers used five measures to gauge the quality of ambulatory care: mammogram screening, annual hemoglobin A1c testing among diabetics, annual lipid testing among diabetics, retina exams among diabetics, and the proportion of diabetic patients who received all three of the diabetic quality measures. As a sixth indicator of quality, the researchers calculated the crude and risk-adjusted numbers of ambulatory care–sensitive admissions, such as admission for hypertension. They estimate that if all physician groups performed at the level of the CAPP-affiliated ones Medicare would save $15 billion per year. W. B. Weeks, D. J. Gottlieb, D. J. Nyweide et al., Higher Health Care Quality and Bigger Savings Found at Large Multispecialty Medical Groups, Health Affairs, May 2010 29(5):991–7.

Errors Go Undetected in Computerized Physician Order Entry Programs
Researchers used a simulation tool to test whether the medication safety decision support that was built into electronic medical records with computerized physician order entry would detect problematic medication orders. They found that decision support detected only 53 percent of medication orders that would have resulted in fatalities and 10 to 82 percent of the test orders that would have caused serious adverse drug events. The categories of adverse events addressed by the simulated test orders included ones for which decision-support tools are fairly straightforward to implement, such as drug-to-drug and drug-to-allergy interactions and therapeutic duplication. The assessment also included test orders that required more effort to customize or configure, such as use of dose calculators. The simulation was conducted in 62 U.S. hospitals, two-thirds of which were teaching hospitals. While researchers found a correlation between performance and choice of software vendor, they found vendor choice accounted for only 27 percent of variation in performance. The study suggests the importance of evaluating whether the implementation of clinical decision support is achieving medication safety goals. J. Metzger, E. Welebob, D. Bates et al., Mixed Results in the Safety Performance of Computerized Physician Order Entry, Health Affairs, April 2010 29(4): 655–62.

Standardized Hospital Mortality Rates a False Signal?
In this commentary, the authors argue that standardized hospital mortality rates are a poor measure of the quality of hospital care and should not trigger public investigations of hospitals as they did in the United Kingdom. The rates do not adequately distinguish preventable from inevitable deaths, they say. In addition, risk adjustment of these rates can amplify the bias that it is intended to reduce. To make their case, the authors point to several findings that demonstrate little correlation between measured quality of care and standardized hospital mortality rates. Instead, they suggest that standardized hospital mortality rates be used to provide a signal to identify when and where further investigation is warranted. They recommend that outcomes in performance measurement be limited to the few circumstances in which they are valid proxies for quality, such as mortality rates associated with high-risk procedures that depend on technical skill. R. Lilford and P. Pronovost, Using Hospital Mortality Rates to Judge Hospital Performance: A Bad Idea that Just Won't Go Away, British Medical Journal, published online April 2010.

Evidence-Based Care Bundles Appear to Reduce Hospital Mortality Rate
An acute hospital trust in northwest London reduced its standardized hospital mortality ratio from 89.6 in 2006–07 to 71.1 in 2007–08, the lowest rate among acute care trusts in England, after targeting the diagnoses responsible for the largest number of deaths for which evidence-based methods to reduce death rates were available. The hospital trust introduced checklists of accepted clinical guidelines for care for those diagnoses. The mortality ratio represents a comparison of the trust to other hospital trusts. A figure of 100 is the national reference value; hospitals with higher or lower adjusted mortality have values above or below 100. During the year of the intervention, there was a 5.7 percent increase in admissions, a 7.9 percent increase in expected deaths, and a 14.5 percent decrease in actual deaths. In the intervention period, 174 fewer deaths occurred in the targeted diagnoses, and 255 fewer deaths in all diagnoses, than if the previous year's adjusted death rates were applied. The study was unable to establish a causal link between the intervention and the death rate; nonetheless, the decline in the death rate occurred only at the site where the checklists were introduced and began in the month of introduction. Further, the decline occurred only for patients with the targeted conditions. E. Robb, B. Jarman, G. Suntharalingam et al., Using Care Bundles to Reduce In-Hospital Mortality: Quantitative Survey, British Medical Journal, April 2010 340:861–3.

Health IT More Beneficial in Teaching Hospitals
Researchers compared the performance of 3,401 nonfederal acute care hospitals on process-of-care measures with their adoption of health information technology (IT). They found the average performance on the process-of-care measures was higher for hospitals that had electronic health record systems and computerized physician order entry, however this difference was statistically significant for only two of the six measures studied: pneumococcal vaccine administration and the use of the most appropriate antibiotics for pneumonia. Focusing on academic hospitals only, the researchers found larger and more significant effects from health IT adoption. The effects of health IT on quality were about threefold larger in academic hospitals than in hospitals on average. The researchers suggest that academic hospitals may use more sophisticated electronic medical records and computerized physician order entry systems than non-teaching hospitals. Alternately, such systems may be more valuable when used for patients with multiple comorbidities, who are more likely to be seen in teaching hospitals than non-teaching hospitals. The researchers say that policies to increase health IT's efficacy in non-teaching hospitals might be more beneficial than subsidies to encourage health IT adoption. J. S. McCullough, M. Casey, I. Moscovice et al., The Effect of Health Information Technology on Quality in U.S., Health Affairs, April 2010 29(4): 647–54.

Reduced Nursing Workloads Linked to Better Outcomes
By comparing nursing workloads in hospitals in California—a state that implemented minimum nurse-to-patient staffing requirements in acute care hospitals in 2004—with those in Pennsylvania and New Jersey, researchers found California's nursing staff ratios were associated with significantly lower mortality and predictive of better nurse retention. The study found nurses in California hospitals cared for one less patient on average than nurses in the other states and two fewer patients on medical and surgical units. Had New Jersey used California's staff ratios, the state would have had 13.9 percent fewer surgical deaths in 2006, while Pennsylvania would have had 10.6 percent fewer, the researchers contend. L. H. Aiken, D. M. Sloane, J.C . Cimiotti et al., Implications of the California Nurse Staffing Mandate for Other States, Health Services Research, Published online April 2010.

Functionality of Electronic Health Record Key to Outcomes
Researchers who tied survey data on use of electronic health records (EHRs) by physician practices with their specific features and the physicians' performance on Healthcare Effectiveness Data and Information Set (HEDIS) measures found that the availability and use of specific EHR features by primary care physicians was associated with higher performance on certain quality measures (including women's health, colon cancer screening, and cancer prevention measures). The association was weaker for measures of asthma and well-child care. Of the EHR functions, the problem list, the visit note, and the radiology test result features seemed to be most useful. The researchers concluded that developers and certifiers of EHRs should focus on increasing the adoption of robust systems and the use of specific features rather than aiming to deploy EHRs without regard to functionality. E. G. Poon, A. Wright, S. Simon et al., Relationship Between Use of Electronic Health Record Features and Health Care Quality: Results of a Statewide Survey, Medical Care, March 2010 48(3):203–9.

Physician Cost Profiles Exhibit High Degree of Unreliability
Researchers who analyzed physician cost profiles that were created using aggregated claims from four health plans in Massachusetts found such measures of resource use had a high degree of unreliability, meaning there was variation in the results that was not attributable to performance. The analysis suggests that current methods for profiling physicians with respect to cost, which are a critical part of some purchasing strategies by insurers, may produce misleading results. According to the study, 22 percent of physicians would have been misclassified as low-cost providers when they were not or misclassified as high-cost providers when they were not. The rate of misclassification ranged from 16 percent for gastroenterologists and otolaryngologists to 36 percent for vascular surgeons. J. L. Adams, A. Mehotra, J. W. Thomas et al., Physician Cost Profiling—Reliability and Risk of Misclassification, New England Journal of Medicine, March 2010 362(11):1014–21.

HEDIS Results Positively Associated with Health Outcome Measures
A study that tested the link between clinical process measures and patient health outcomes by relating health plans' performance on the 2002 Healthcare Effectiveness Data and Information Set (HEDIS) measures to changes in enrollees' health status between 2001 and 2003 found a positive effect between the two in the population studied—patients who reported having diabetes. The researchers found each 10 percentage point improvement in performance on the HEDIS measures for the proportion of patients with well-controlled diabetes was related to a 7 percentage point increase in the probability of being healthy as measured by enrollees' physical health scores and a 11 percentage point increase in the probability of being healthy as measured by mental health scores. J. Harman, S. H. Scholle, J. H. Ng et al., Association of Health Plans' Healthcare Effectiveness Data and Information Set Performance with Outcomes of Enrollees with Diabetes, Medical Care, March 2010 48(3):217–23.

Research on the Role of EHRs in Care Coordination Needed
An editorial highlighting a previous study published in the Journal of General Internal Medicine, which found current electronic health records (EHRs) do not support care coordination, calls for research into how EHRs can support care coordination, which is critical to improving the care of patients who suffer from chronic disease and account for nearly three-quarters of all health care expenditures. The author points out that medical practices do not have well-developed processes for care coordination. He also suggests that the definition of "meaningful use" of health information technology being developed by the Office of the National Coordinator for Health Information Technology should take into account the research by Ann S. O'Malley and colleagues. D. W. Bates, Getting in Step: Electronic Health Records and Their Role in Care Coordination, Journal of General Internal Medicine, March 2010 25(3):174–6.

Quality of Cardiac Care Inversely Related to a Hospital's Proportion of Low-Income Patients
A study that examined the relationship between a hospital's proportion of low-income patients and the quality of in-hospital cardiac care as measured by adherence to 12 quality-of-care measures for acute myocardial infarction and heart failure found adherence to these process measures declined as the proportion of low-income patients increased. Even after controlling for hospital characteristics, the proportion of low-income patients was inversely and significantly associated with hospital performance on each of the acute myocardial infarction and heart failure measures, with the exception of two heart failure measures (provision of discharge instructions and use of ACE inhibitors for left ventricular systolic dysfunction). The researchers point out that such disparities may increase if pay-for-performance programs based on quality measures are implemented in these hospitals. S. D. Culler, L. Schieb, M. Casper et al., Is There an Association Between Quality of In-Hospital Cardiac Care and Proportion of Low-Income Patients?, Medical Care, March 2010 48(3):273–8.


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