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 2012 Issue
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Publications of Note

Patient Engagement Linked to Improved Diabetes Management
A study examining the association between patients' use of a personal health record (PHR) linked to an electronic medical record and diabetes control in adults found that PHR use was associated with improved performance on measures of hemoglobin A1c, blood pressure, and body mass index, among others. The study also found that compared with non-users, PHR users were younger, had higher incomes and educational attainment, were more likely to identify as Caucasian, and had better unadjusted and adjusted performance on measures of diabetes management. The authors concluded that better diabetes management among PHR users is due to their higher level of engagement with health rather than PHR use itself. M. Tenforde, A. Nowacki, A. Jain et al., "The Association Between Personal Health Record Use and Diabetes Quality Measures," Journal of General Internal Medicine, April 2012 27(4):420–24. 

Performance Measurement Leads to Some Negatives Consequences in VHA Facilities
A study designed to identify the unintended negative consequences of performance measurement systems examined the effect of them in Veterans Health Administration (VHA) facilities. The authors relied on in-person interviews with primary care staff and facility leaders at four VHA facilities and noted both positive effects and negative unintended consequences of performance measurement, including inappropriate clinical care, decreased provider focus on patient concerns and patient service, and compromised patient education and autonomy. The authors concluded that further research is needed to determine how features of centralized performance measurement systems influence whether such measures are translated by facilities into more or less patient-centered policies and processes. A. A. Powell, K. M. White, M. R. Partin et al., "Unintended Consequences of Implementing a National Performance Measurement System into Local Practice," Journal of General Internal Medicine, April 2012 27(4):405–12. 

Negative Consequences of Performance Measurement at VHA Explained
This commentary, which accompanied a journal article on some of the negative unintended consequences of the Veteran Health Administration's performance measurement system, offers some insights into the system's potential problems. Rather than encouraging local innovation, the authors note performance measurement at the VHA has become more retrospectively focused on compliance with centrally promulgated national policies and performance goals that may stem from outlier events. The number of performance measures has also markedly increased as has the use of less sensitive dichotomous or composite measures. The opportunity for clinicians to receive financial incentives for performance also influences their focus. The factors combined appear to dampen willingness to innovate and encourage behaviors aimed at heightening performance, the authors note. K. W. Kizer and S. R. Hirsh, "The Double Edged Sword of Performance Measurement," Journal of General Internal Medicine, April 2012 27(4):395–7. 

Challenges of Using Hospital-Wide Mortality Rates
The authors of this article outline several conceptual and methodological concerns with the use of hospital-wide mortality rates as a measure of overall hospital quality. These include the concern that for many diagnoses included in hospital-wide mortality rates, the association between short-term mortality and quality of care is not well established. In addition, compared with condition-specific or procedure-specific mortality rates, hospital-wide mortality rates pose methodological challenges with risk adjustment and statistical techniques for aggregating across diagnoses. The authors suggest potential alternative approaches including the use of multidimensional composite metrics or mortality measurement limited to selected conditions and procedures for which the link between hospital mortality and quality is clear, legitimate exclusions are uncommon, and sample sizes, end points, and risk adjustment are adequate. D. M. Shahian, L. I. Iezzoni, G. S. Meyer et al., "Hospital-Wide Mortality as a Quality Metric: Conceptual and Methodological Challenges," American Journal of Medical Quality, March/April 2012 27: 112–23. 

Patients Equate High-Cost Providers with High Quality
A study of 1,421 employees who examined different presentations of quality and cost information found a substantial minority of respondents shied away from low-cost providers, and even consumers who pay a larger share of their health care costs themselves were likely to equate high cost with high quality. At the same time, the authors found that presenting cost data alongside easy-to-interpret quality information and highlighting high-value options improved the likelihood that consumers would choose those options. The authors suggest that reporting strategies that follow such a format will help consumers understand that a physician who provides higher-quality care than other physicians does not necessarily cost more. J. Hibbard, J. Greene, S. Sofaer et al., "An Experiment Shows That a Well-Designed Report on Costs and Quality Can Help Consumers Choose High-Value Health Care," Health Affairs, March 2012 31(3):560–8. 

Public Reporting Improves Diabetes Care
A survey of more than 400 primary care clinics that have been publicly reporting data on how well they deliver diabetes care found that such public reporting helped drive early adoption of diabetes care improvement activities, including patient registries and care reminders. Public reporting also seems to have promoted the adoption of multiple improvement interventions over time. The study found implementation of diabetes care interventions among the collaborative's physician groups increased notably from 2003 to 2008, by which time nearly half of the clinics had implemented 11 or more interventions. There was also steady growth in use of "best practices," including use of telephone and mail reminders to patients about upcoming appointments or tests; prompts to providers about recommended care; diabetes care guidelines and/or protocols; patient registries; and inclusion of specialists, such as endocrinologists, in care teams. M. A. Smith, A. Wright, C. Queram et al., "Public Reporting Helped Drive Quality Improvement in Outpatient Diabetes Care Among Wisconsin Physician Groups," Health Affairs, March 2012 31(3):570–7. 

Experts Express Concerns About Public Reporting Methods
Researchers who interviewed experts and surveyed stakeholders involved in the public reporting of health care quality data found of 29 experts interviewed, 12 said that current physician report cards needed either modest changes or total revamping while 13 of the interviewees felt that report cards needed changes somewhere between these two options. The majority of interviewees also felt that consumers are unaware that these report cards are publicly available or that they are unable to use the information provided. Among the interviewees, there was broad consensus that measures currently reported are not well suited to helping consumers make more informed health care choices. The six challenges facing public reporting efforts, as identified by interviewees, include: a lack of consumer readiness and engagement, opposition from providers, a lack of funding, political obstacles, insufficient data infrastructure, and the inadequacy of current measurement science. A. Sinaiko, D. Eastman, and M. Rosenthal, "How Report Cards on Physicians, Physician Groups, and Hospitals Can Have Greater Impact on Consumer Choices," Health Affairs, March 2012 31(3):602–11. 

Checklist for Reducing Provider Misclassification in Public Reporting Outlined
An article on improving public reporting recommends that report makers rely on a five-point methodological checklist to minimize the frequency and severity of provider performance misclassification and avoid adverse unintended consequences of reporting. The checklist encourages those reporting performance to: 1) measure and address systematic misclassification of providers by stratifying results by different patient characteristics; 2) measure and address random misclassification that occurs when there is low measurement reliability; 3) use composite scores appropriately to avoid oversimplifying or distorting the true nature of provider performance; 4) perform sensitivity analyses; and 5) measure the effects of reporting. M. W. Friedberg and C. L. Damberg, "A Five-Point Checklist to Help Performance Reports Incentivize Improvement and Effectively Guide Patients," Health Affairs, March 2012 31(3):612–8.

Higher Spending in Canadian Hospitals Linked to Lower Mortality and Readmissions
A study designed to assess whether acute care patients admitted to higher-spending hospitals have lower mortality and readmission rates found that among hospitals in Ontario, Canada, higher spending intensity was associated with lower mortality, readmission, and cardiac event rates. The study population included adults with a first admission for acute myocardial infarction, congestive heart failure, hip fracture, or colon cancer. To gauge spending, the authors relied on the hospital's end-of-life expenditure index for hospital, physician, and emergency department services. The study also found higher-spending hospitals had higher nurse-to-patient ratios and their patients received more inpatient medical specialist visits, interventional and medical cardiac therapies, preoperative specialty care, and postdischarge collaborative care with a cardiologist and/or primary care physician. T. A. Stukel, E. S. Fisher, D. A. Alter et al., "Association of Hospital Spending Intensity with Mortality and Readmission Rates in Ontario Hospitals," Journal of the American Medical Association, March 2012:307(10):1037–45. 

Use of Patient-Centeredness Measures in Quality Assessments Recommended
The authors of this commentary note that assessments of quality of care and health outcomes have not incorporated information on patient-centeredness, but rather have addressed preventive and disease-specific care processes. Outcomes measures similarly focus on condition-specific indicators. While these measures may work well for healthy patients with single diseases, the authors point out they may be inappropriate for patients with multiple conditions, severe disability, or short life expectancy. They propose an alternative approach that focuses on a patient's individual health goals within or across a variety of dimensions, including physical functional status, mobility, social and role functions, and symptoms. D. E. Reuben and N. E. Tinetti, "Goal-Oriented Patient Care—An Alternative Health Outcomes Paradigm," New England Journal of Medicine, March 2012 366 (9):777–9. 

Quality Improvement Program Leads to Reduced Asthma-Related ED Visits and Hospitalizations
A study that sought to assess the cost-effectiveness of a quality improvement program demonstrated a significant decrease in asthma-related emergency department visits (68.0%), hospitalizations (84.8%), days of limited physical activity (42.6%), missed school days (41.0%), and missed workdays for parents (49.7%) There was also a significant reduction in hospital costs compared with the comparison community and a return on investment of 1.46. E. R. Woods, U. Bhaumik, and S. J. Sommer, "Community Asthma Initiative: Evaluation of a Quality Improvement Program for Comprehensive Asthma Care," Pediatrics, March 2012 129(3):465–72. 

Quality Measures for Complex Pediatric Care Rated
A study designed to identify valid and meaningful quality measures for use in complex pediatric patients convened a national expert panel to evaluate and rate quality measures. The 35 resulting measures were grouped into the following domains: primary care, patient/family-centered care, chronic care, coordination of care, and transition of care. A. Y. Chen, S. M. Schrager, and R. Mangione-Smith, "Quality Measures for Primary Care of Complex Pediatric Patients," Pediatrics, March 2012 129(3):433–445. 

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