Medical Homes' Effect on Quality May Be More Modest Than Expected
A review of publications focusing on implementations of the patient-centered medical home (PCMH) model found it has a small, positive effect on patient experiences; a small-to-moderate effect on receipt of preventive services; and a small-to-moderate impact on staff experiences. The authors say more research is needed to determine the impact of the model on clinical and economic outcomes. G. L. Jackson, B. J. Powers, R. Chatterjee et al. "The Patient-Centered Medical Home: A Systematic Review, Annals of Internal Medicine, Feb. 2013 158(3):169–78.
Electronic Reporting of Some Quality Measures Inaccurate
A study that compared the accuracy of electronically reported quality measures with those obtained through a manual review of medical charts found electronic reporting underestimated rates of appropriate asthma medication and pneumococcal vaccination compared with manual review of charts. The study also found that electronic reporting overestimated the rate of cholesterol control in patients with diabetes. The authors note the underestimates may result from the practice of recording the delivery of recommended care in free-text notes or scanned documents rather than in structured fields. But if the variation is not addressed, they say financial incentives that reward high quality may not be given to the highest-quality providers. The authors also suggest that national programs linking financial incentives to quality reporting should require electronic health record vendors to demonstrate the accuracy of their automated reports. L. M. Kern, S. Malhotra, Y. Barrón et al., "Accuracy of Electronically Reported 'Meaningful Use' Clinical Quality Measures: A Cross-Sectional Study," Annals of Internal Medicine, Jan. 2013 158(2):77–83.
Relationship Between Cost and Quality Varies Across Studies
A study of publications assessing the association between costs and quality found that slightly more than one-third (34%) found higher cost is associated with higher quality; 30 percent reported negative or mixed-negative association between cost and quality; and 36 percent reported no difference, an imprecise or indeterminate association, or a mixed association. Because most of the studies found that the association between cost and quality is small to moderate regardless of whether the direction is positive or negative, the authors suggest that future studies focus on what types of spending are most effective in improving quality and what types of spending represent waste. P. S. Hussey, S. Wertheimer, and A. Mehrotra, "The Association Between Health Care Quality and Cost: A Systematic Review," Annals of Internal Medicine, Jan. 2013 158(1):27–34.
As Length of Stay at VA Hospitals Declined, So Did Readmission Rates
A study that sought to determine whether reductions in length of stay at Veterans Affairs (VA) hospitals led to increased readmissions found that although lengths of stay at 129 hospitals decreased by 27 percent between 1997 and 2010 for five common conditions, there was no increase in readmissions. In fact, readmission rates decreased by 16 percent during the same period. The authors also found no evidence for increased mortality rates; all-cause mortality at 30 and 90 days after admission decreased by 3.4 percent and 3 percent, respectively, during each year over this period. Among the possible explanations for the results: VA hospitals may have prolonged hospitalizations beyond what was necessary, and thus a reduction in days would not lead to a premature discharge; a VA-wide emphasis on medication reconciliation at care transitions; and the use of hospitalists. P. J. Kaboli, J. T. Go, J. Hockenberry et al., "Associations Between Reduced Hospital Length of Stay and 30-Day Readmission Rate and Mortality: 14-Year Experience in 129 Veterans Affairs Hospitals," Annals of Internal Medicine, Dec. 2012 157(12): 837–45.
In Controlled Studies, P4P Did Not Improve Quality of Care
A review of 30 studies that compared pay-for-performance programs (P4P) with other remuneration models for individual clinicians found that while uncontrolled studies suggest P4P programs improve quality of care, higher-quality studies with contemporaneous controls did not confirm these findings. The authors concluded that the evidence base is not yet robust enough to support widespread implementation of P4P programs. They also suggest future research is necessary to evaluate the role of organizational factors in facilitating or impeding the implementation and effectiveness of P4P programs. S. K. D. Houle, F. A. McAlister, C. A. Jackevicius et al., "Does Performance-Based Remuneration for Individual Health Care Practitioners Affect Patient Care?: A Systematic Review," Annals of Internal Medicine, Dec. 2012 157(12):889–89.
Patient Activation Linked to Better Health Outcomes
A review of evidence on the association between patient activation and health outcomes, costs, and patient experience found that having the skills and confidence to actively engage in one's health care is linked to better health outcomes and care experiences. Patients with higher scores on the Patient Activation Measure are more likely to obtain regular check-ups, screenings, and immunizations. They are also significantly more likely to engage in healthy behavior such as eating a healthy diet and getting regular exercise, while less activated patients were three times as likely to have unmet medical needs and twice as likely to delay medical care. Although evidence of patient activation's impact on cost is limited, the authors note that after disease severity and demographic characteristics were controlled for, highly activated patients had lower rates of costly use of hospitals and emergency departments. The studies also show that activation can be modified and increased over time and that patients who start at the lowest activation levels tend to increase the most. J. H. Hibbard and J. Greene, "What the Evidence Shows About Patient Activation: Better Health Outcomes and Care Experiences; Fewer Data on Costs," Health Affairs, Feb. 2013 32(2):207–14.
Cost of Care Lower Among Patients with High Activation Scores
A related study that sought to determine whether patients who are more activated have lower overall cost of care—perhaps because they are less likely to use the emergency department or be hospitalized or because they are more likely to adhere to treatment regimens—found that patient activation was negatively associated with cost of care. Also, patients with low activation levels had costs that were 21 percent higher than patients with the highest level of activation, a difference most pronounced with patients with asthma. The study relied on data from primary care patients enrolled with Fairview Health Services in Minnesota. J. H. Hibbard, J. Greene, and V. Overton, "Patients with Lower Activation Associated with Higher Costs; Delivery Systems Should Know Their Patients' 'Scores'," Health Affairs, Feb. 2013 32(2):216–22.
Lessons from Engaging Patients in Four Communities
An article reviewing the evidence on the effects of patient engagement on care delivery describes the work of four communities participating in the Robert Wood Johnson Foundation's Aligning Forces for Quality initiative, which aims to improve the overall quality of care in targeted areas and to reduce racial and ethnic disparities in care. The four profiled communities are actively engaging patients in improving quality in ambulatory care settings; early lessons from that work suggest that actively engaging patients improves provider–patient communication, helps to streamline care processes, and improves provider and patient satisfaction. D. Roseman, J. Osborne-Stafsnes, C. H. Amy et al., "Early Lessons from Four 'Aligning Forces for Quality' Communities Bolster the Case for Patient-Centered Care," Health Affairs, Feb. 2013 32(2):232–241.
Benefit of EHRs Takes Time and Technical Support to Realize
To investigate the impact of electronic health record (EHR) adoption in small primary care practices and to determine whether the regional extension model of technical assistance improves quality, researchers studied the New York City Primary Care Information Project, the largest community-based EHR implementation and regional extension program in the U.S. They found that general participation in the project was not enough to improve quality of care. It took sustained exposure to the program and technical assistance before the practices demonstrated improvement on measures of care most likely to be affected by the use of electronic health records, such as cancer screenings and care for patients with diabetes. Participating in the Primary Care Information Project for nine or more months was associated with significantly improved quality, but only for a limited group of quality measures and only for physicians receiving extensive technical assistance. A. M. Ryan, T. F. Bishop, S. Shih et al., "Small Physician Practices in New York Needed Sustained Help to Realize Gains in Quality from Use of Electronic, Health Records," Health Affairs, Jan. 2013 32(1):53–62.
Patients' Heightened Vulnerability Following Hospitalization May Account for Some Readmissions
A study of Medicare beneficiaries who were readmitted to hospitals within 30 days of hospitalization for heart failure, acute myocardial infarction, or pneumonia found that the reason for readmission usually differed from the cause of the index admission. The study also found that although a disproportionately high number of readmissions occurred soon after discharge, readmissions remained frequent throughout the month—suggesting the entire 30-day period after discharge is one of heightened vulnerability for patients. This may explain why approaches with multiple components or interventions delivered by a multidisciplinary team are more likely to be effective at reducing admissions, the authors say. K. Dharmarajan, A. F. Hsieh, Z. Lin et al., "Diagnoses and Timing of 30-Day Readmissions After Hospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumonia," Journal of the American Medical Association, Jan. 23/30 2013 309(4):355–63.
Center of Excellence Not Necessarily Better
An evaluation of a centers-of-excellence program for knee and hip replacement found that compared with other hospitals, those designated as centers of excellence had lower rates of complications for hip replacement, but there was no statistically significant difference for knee replacement. Ninety-day costs did not significantly differ between centers of excellence and other hospitals, the authors found. They say encouraging patients to switch to designated hospitals may be premature until selection criteria is developed to identify hospitals with superior outcomes. A. Mehrotra, E. M. Sloss, P. S. Hussey et al., "Evaluation of Centers of Excellence Program for Knee and Hip Replacement," Medical Care, Jan. 2013 51(1):28–36.
Attention to Patient Vulnerability Following Hospitalization Necessary to Reduce Readmissions
The author of this commentary suggests that promoting a successful recovery after a hospitalization may require health care professionals to recognize that patients experience a period of generalized risk for a range of adverse events at the time of discharge because their physiological systems are impaired, making it difficult for them to defend against other health threats. In addition to improving transitional care for the conditions for which the patient was hospitalized, providers should also focus on the factors during the hospitalization and the early recovery period that contribute to the period of vulnerability. H. M. Krumholz, "Post-Hospital Syndrome—An Acquired, Transient Condition of Generalized Risk," New England Journal of Medicine, Jan. 2013 368(2):100–2.
A review of publications focusing on implementations of the patient-centered medical home (PCMH) model found it has a small, positive effect on patient experiences; a small-to-moderate effect on receipt of preventive services; and a small-to-moderate impact on staff experiences. The authors say more research is needed to determine the impact of the model on clinical and economic outcomes. G. L. Jackson, B. J. Powers, R. Chatterjee et al. "The Patient-Centered Medical Home: A Systematic Review, Annals of Internal Medicine, Feb. 2013 158(3):169–78.
Electronic Reporting of Some Quality Measures Inaccurate
A study that compared the accuracy of electronically reported quality measures with those obtained through a manual review of medical charts found electronic reporting underestimated rates of appropriate asthma medication and pneumococcal vaccination compared with manual review of charts. The study also found that electronic reporting overestimated the rate of cholesterol control in patients with diabetes. The authors note the underestimates may result from the practice of recording the delivery of recommended care in free-text notes or scanned documents rather than in structured fields. But if the variation is not addressed, they say financial incentives that reward high quality may not be given to the highest-quality providers. The authors also suggest that national programs linking financial incentives to quality reporting should require electronic health record vendors to demonstrate the accuracy of their automated reports. L. M. Kern, S. Malhotra, Y. Barrón et al., "Accuracy of Electronically Reported 'Meaningful Use' Clinical Quality Measures: A Cross-Sectional Study," Annals of Internal Medicine, Jan. 2013 158(2):77–83.
Relationship Between Cost and Quality Varies Across Studies
A study of publications assessing the association between costs and quality found that slightly more than one-third (34%) found higher cost is associated with higher quality; 30 percent reported negative or mixed-negative association between cost and quality; and 36 percent reported no difference, an imprecise or indeterminate association, or a mixed association. Because most of the studies found that the association between cost and quality is small to moderate regardless of whether the direction is positive or negative, the authors suggest that future studies focus on what types of spending are most effective in improving quality and what types of spending represent waste. P. S. Hussey, S. Wertheimer, and A. Mehrotra, "The Association Between Health Care Quality and Cost: A Systematic Review," Annals of Internal Medicine, Jan. 2013 158(1):27–34.
As Length of Stay at VA Hospitals Declined, So Did Readmission Rates
A study that sought to determine whether reductions in length of stay at Veterans Affairs (VA) hospitals led to increased readmissions found that although lengths of stay at 129 hospitals decreased by 27 percent between 1997 and 2010 for five common conditions, there was no increase in readmissions. In fact, readmission rates decreased by 16 percent during the same period. The authors also found no evidence for increased mortality rates; all-cause mortality at 30 and 90 days after admission decreased by 3.4 percent and 3 percent, respectively, during each year over this period. Among the possible explanations for the results: VA hospitals may have prolonged hospitalizations beyond what was necessary, and thus a reduction in days would not lead to a premature discharge; a VA-wide emphasis on medication reconciliation at care transitions; and the use of hospitalists. P. J. Kaboli, J. T. Go, J. Hockenberry et al., "Associations Between Reduced Hospital Length of Stay and 30-Day Readmission Rate and Mortality: 14-Year Experience in 129 Veterans Affairs Hospitals," Annals of Internal Medicine, Dec. 2012 157(12): 837–45.
In Controlled Studies, P4P Did Not Improve Quality of Care
A review of 30 studies that compared pay-for-performance programs (P4P) with other remuneration models for individual clinicians found that while uncontrolled studies suggest P4P programs improve quality of care, higher-quality studies with contemporaneous controls did not confirm these findings. The authors concluded that the evidence base is not yet robust enough to support widespread implementation of P4P programs. They also suggest future research is necessary to evaluate the role of organizational factors in facilitating or impeding the implementation and effectiveness of P4P programs. S. K. D. Houle, F. A. McAlister, C. A. Jackevicius et al., "Does Performance-Based Remuneration for Individual Health Care Practitioners Affect Patient Care?: A Systematic Review," Annals of Internal Medicine, Dec. 2012 157(12):889–89.
Patient Activation Linked to Better Health Outcomes
A review of evidence on the association between patient activation and health outcomes, costs, and patient experience found that having the skills and confidence to actively engage in one's health care is linked to better health outcomes and care experiences. Patients with higher scores on the Patient Activation Measure are more likely to obtain regular check-ups, screenings, and immunizations. They are also significantly more likely to engage in healthy behavior such as eating a healthy diet and getting regular exercise, while less activated patients were three times as likely to have unmet medical needs and twice as likely to delay medical care. Although evidence of patient activation's impact on cost is limited, the authors note that after disease severity and demographic characteristics were controlled for, highly activated patients had lower rates of costly use of hospitals and emergency departments. The studies also show that activation can be modified and increased over time and that patients who start at the lowest activation levels tend to increase the most. J. H. Hibbard and J. Greene, "What the Evidence Shows About Patient Activation: Better Health Outcomes and Care Experiences; Fewer Data on Costs," Health Affairs, Feb. 2013 32(2):207–14.
Cost of Care Lower Among Patients with High Activation Scores
A related study that sought to determine whether patients who are more activated have lower overall cost of care—perhaps because they are less likely to use the emergency department or be hospitalized or because they are more likely to adhere to treatment regimens—found that patient activation was negatively associated with cost of care. Also, patients with low activation levels had costs that were 21 percent higher than patients with the highest level of activation, a difference most pronounced with patients with asthma. The study relied on data from primary care patients enrolled with Fairview Health Services in Minnesota. J. H. Hibbard, J. Greene, and V. Overton, "Patients with Lower Activation Associated with Higher Costs; Delivery Systems Should Know Their Patients' 'Scores'," Health Affairs, Feb. 2013 32(2):216–22.
Lessons from Engaging Patients in Four Communities
An article reviewing the evidence on the effects of patient engagement on care delivery describes the work of four communities participating in the Robert Wood Johnson Foundation's Aligning Forces for Quality initiative, which aims to improve the overall quality of care in targeted areas and to reduce racial and ethnic disparities in care. The four profiled communities are actively engaging patients in improving quality in ambulatory care settings; early lessons from that work suggest that actively engaging patients improves provider–patient communication, helps to streamline care processes, and improves provider and patient satisfaction. D. Roseman, J. Osborne-Stafsnes, C. H. Amy et al., "Early Lessons from Four 'Aligning Forces for Quality' Communities Bolster the Case for Patient-Centered Care," Health Affairs, Feb. 2013 32(2):232–241.
Benefit of EHRs Takes Time and Technical Support to Realize
To investigate the impact of electronic health record (EHR) adoption in small primary care practices and to determine whether the regional extension model of technical assistance improves quality, researchers studied the New York City Primary Care Information Project, the largest community-based EHR implementation and regional extension program in the U.S. They found that general participation in the project was not enough to improve quality of care. It took sustained exposure to the program and technical assistance before the practices demonstrated improvement on measures of care most likely to be affected by the use of electronic health records, such as cancer screenings and care for patients with diabetes. Participating in the Primary Care Information Project for nine or more months was associated with significantly improved quality, but only for a limited group of quality measures and only for physicians receiving extensive technical assistance. A. M. Ryan, T. F. Bishop, S. Shih et al., "Small Physician Practices in New York Needed Sustained Help to Realize Gains in Quality from Use of Electronic, Health Records," Health Affairs, Jan. 2013 32(1):53–62.
Patients' Heightened Vulnerability Following Hospitalization May Account for Some Readmissions
A study of Medicare beneficiaries who were readmitted to hospitals within 30 days of hospitalization for heart failure, acute myocardial infarction, or pneumonia found that the reason for readmission usually differed from the cause of the index admission. The study also found that although a disproportionately high number of readmissions occurred soon after discharge, readmissions remained frequent throughout the month—suggesting the entire 30-day period after discharge is one of heightened vulnerability for patients. This may explain why approaches with multiple components or interventions delivered by a multidisciplinary team are more likely to be effective at reducing admissions, the authors say. K. Dharmarajan, A. F. Hsieh, Z. Lin et al., "Diagnoses and Timing of 30-Day Readmissions After Hospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumonia," Journal of the American Medical Association, Jan. 23/30 2013 309(4):355–63.
Center of Excellence Not Necessarily Better
An evaluation of a centers-of-excellence program for knee and hip replacement found that compared with other hospitals, those designated as centers of excellence had lower rates of complications for hip replacement, but there was no statistically significant difference for knee replacement. Ninety-day costs did not significantly differ between centers of excellence and other hospitals, the authors found. They say encouraging patients to switch to designated hospitals may be premature until selection criteria is developed to identify hospitals with superior outcomes. A. Mehrotra, E. M. Sloss, P. S. Hussey et al., "Evaluation of Centers of Excellence Program for Knee and Hip Replacement," Medical Care, Jan. 2013 51(1):28–36.
Attention to Patient Vulnerability Following Hospitalization Necessary to Reduce Readmissions
The author of this commentary suggests that promoting a successful recovery after a hospitalization may require health care professionals to recognize that patients experience a period of generalized risk for a range of adverse events at the time of discharge because their physiological systems are impaired, making it difficult for them to defend against other health threats. In addition to improving transitional care for the conditions for which the patient was hospitalized, providers should also focus on the factors during the hospitalization and the early recovery period that contribute to the period of vulnerability. H. M. Krumholz, "Post-Hospital Syndrome—An Acquired, Transient Condition of Generalized Risk," New England Journal of Medicine, Jan. 2013 368(2):100–2.
