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 2011 Issue
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Publications of Note

V.A. Outperforms Medicare Advantage on Quality and Disparities
A study that compared the quality and equity of care for older adults in the V.A. with that delivered in Medicare Advantage health plans found the V.A. outperformed the Medicare Advantage plans on 10 of 11 quality measures in the initial study year, and on all 12 quality measures in the final year. The study looked at measures of adherence to diabetes, cardiovascular, and cancer screening care recommendations from 2000 to 2007. The adjusted differences between the V.A. and the Medicare Advantage plans ranged from 4.3 percentage points for cholesterol testing in patients with coronary heart disease to 30.8 percentage points for colorectal cancer screening. For nine of the 12 measures, socioeconomic disparities were lower in the V.A. than in the Medicare Advantage plans. A. N. Trivedi and R. C. Grebla, "Quality and Equity of Care in the Veterans Affairs Health-Care System and in Medicare Advantage Health Plans," Medical Care, June 2011 49(6):560-68.

Patient Engagement Tied to Fewer Adverse Events in Hospitals
A study that examined the impact of hospitalized patients' participation in their care found that high participation (defined as use of more than four activities such as checking medicines given by hospital staff) was strongly associated with patients' favorable ratings of the hospital quality of care. The study also found an inverse relationship between participation and adverse events; patients with high participation were half as likely to have at least one adverse event during the admission. S. N. Weingart, J. Zhu, L. Chippetta et al., "Hospitalized Patients' Participation and Its Impact on Quality of Care and Patient Safety," International Journal of Quality in Health Care, June 2011 23(3):269-77.

Use of Standardized Form Improves Documentation of Foot Exams
A quality improvement program designed to increase the frequency of comprehensive diabetic foot exams (CDFEs) at a large, multispecialty ambulatory care practice, found the use of a standardized documentation form resulted in more consistent and complete documentation of annual CDFEs. An audit found that 44.5 percent of dictated notes lacked one or more of the components of the CDFE, whereas only 4 percent of the electronic medical records, which used the standardized form, lacked one or more of the three components of the CDFE. The quality improvement program also included provider and staff education, an electronic reminder, and a well-defined process. T.A. Praxel, T.J. Ford, and E.W. Vanderboom, "Improving the Efficiency and Effectiveness of Performing the Diabetic Foot Exam," American Journal of Medical Quality, May/June 2011 26(3): 193-99.

Study Finds Reach and Value of RHIOs Limited
A study designed to assess the effectiveness of regional health information organizations (RHIOs), which help local hospitals and providers exchange health information, found only 75 of 165 RHIOs participating in a survey were operational; the functioning RHIOs covered just 14 percent of U.S. hospitals and 3 percent of ambulatory practices. The study also found only 13 RHIOs supported providers in adopting electronic health records that met the government's meaningful use standard. None met the expert-derived definition of a comprehensive RHIO. The paper calls into question whether RHIOs in their current form can be self-sustaining and effective at helping U.S. physicians and hospitals engage in health information exchange that improves the quality and efficiency of care. J. Adler-Milstein, D. W. Bates, and A. K. Jha, "A Survey of Health Information Exchange Organizations in the United States: Implications for Meaningful Use," Annals of Internal Medicine, May 2011 154(10):666-71.

Expert Recommendations on Patient Safety Research Released
An international group of experts in patient safety, which met to develop criteria to improve the design, evaluation, and reporting of practice research in patient safety, developed a number of recommendations to advance the field. For example, the group suggested researchers make greater use of theory and logic models, give more detailed descriptions of interventions and their implementation, and enhance their explanations of desired and unintended outcomes. P. G. Shekelle, P. J. Pronovost, R. M. Wachter et al., "Advancing the Science of Patient Safety," Annals of Internal Medicine, May 2011, 154(10):693-96.

A Call to Refine the Science of Safety
In an editorial, Carolyn Clancy, M.D., director of the Agency for Healthcare Research and Quality, and Don Berwick, M.D., M.P.P., administrator of the Centers for Medicare and Medicaid Services, stressed the importance of finding ways of translating research on patient safety improvement into practical and actionable advice for hospitals and clinicians. To facilitate comparisons of implementation strategies, hospitals and clinicians will need to measure organizational variables such as staffing, and clinical outcomes, within a common evaluation framework. C. M. Clancy and D. M. Berwick, "The Science of Safety Improvement: Learning While Doing," Annals of Internal Medicine, May 2011 154(10):699-701.

Full-Time Providers Linked to Fewer Hospitalizations Among Nursing Home Patients
A comparison of two models of primary care in four different continuing care retirement communities found that having a dedicated group of physicians and nurse practitioners that exclusively delivered care at the site, covered all settings within it, and provided all after-hours coverage, resulted in two to three times fewer hospitalizations and emergency department visits. In contrast, residents of institutions that relied on physicians that worked part-time at the retirement community and had independent practices outside of it, were more likely to die in a hospital that those that received continuous care from one group of providers (15% vs. 5%). J. P. W. Bynum, A. Andrews, S. Sharp et al., "Fewer Hospitalizations Result When Primary Care Is Highly Integrated Into A Continuing Care Retirement Community," Health Affairs, May 2011 30(5):975-84.

More Primary Care Providers Leads to Fewer Hospitalizations and Lower Mortality Rates
A study that measured the association between the primary care capacity and individual patient outcomes found that Medicare beneficiaries living in areas with the highest level of primary care physicians per capita had modestly lower mortality and fewer ambulatory care sensitive hospitalizations. Stronger associations were observed for mortality and ambulatory care sensitive hospitalizations when the measure of the workforce reflected physicians delivering ambulatory primary care services as opposed to primary care physicians per capita, suggesting that the benefits of the primary care workforce are from the amount of ambulatory clinical care provided, rather than the number of primary care physicians locally available. C. H. Chang, T. A. Stukel, A. B. Flood et al., "Primary Care Physician Workforce and Medicare Beneficiaries' Health Outcomes," Journal of the American Medical Association, May 2011 305(20):2096-2104.

A Map to High Reliability
The authors of this paper review the evolution of quality improvement in U.S. health care and propose a framework that hospitals and other organizations can use to move toward highly reliable care. Among their recommendations: leadership must make a commitment to the goal of high reliability, the organizational culture that supports high reliability must be fully implemented, and the tools of robust process improvement must be adopted. M. R. Chassin and J. M. Loeb, "The Ongoing Quality Improvement Journey: Next Stop, High Reliability," Health Affairs, April 2011 30(4):559-68.

Low Literacy Associated with Higher Mortality Rates
A study of outpatients with heart failure at Kaiser Permanente Colorado found that low health literacy was significantly associated with higher all-cause mortality. The study also found that patients with low health literacy were older, of lower socioeconomic status, less likely to have at least a high school education, and had higher rates of coexisting illnesses. P. N. Peterson, S. M. Shetterly, C. L. Clarke et al., "Health Literacy and Outcomes Among Patients With Heart Failure," Journal of the American Medical Association, April 2011 305(16):1695-1701.

Copay Levels Have Less Influence on Physician Choice Than Friends and Family
A study that assessed how financial incentives and quality information from multiple sources affect consumer choice of physicians in tiered physician networks found that copayments must exceed $300 to counteract the recommendation from friends, family, or a referring physician to a physician in the nonpreferred tier. The authors concluded that lower copayment levels ($10 to $35) have limited influence on physician choice when contradicted by other trusted sources. The survey, which relied on a sample of Massachusetts state employees, suggests consumers' response likely varies with physician specialty. A. D. Sinaiko, "How Do Quality Information and Cost Affect Patient Choice of Provider in a Tiered Network Setting? Results from a Survey," Health Services Research, April 2011 46(2):437-56.

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