Commentary: Nuanced Approach to Adjusting Hospital Performance to Account for Socioeconomic Status Needed
A commentary in the Journal of the American Medical Association exploring how and whether to adjust hospital performance measures for socioeconomic characteristics makes several recommendations to encourage improvement without penalizing hospitals caring for a disproportionate number of poor patients, whose treatment outcomes may be influenced by factors outside of a hospital’s control. The authors suggest using unadjusted scores to identify a hospital’s overall performance and areas for improvement, and recommend relying on adjusted scores to determine the likely experience of a hospital patient given his or her socioeconomic status and to create financial incentives for improvement. A. K. Jha and A. M. Zaslavsky, “Quality Reporting That Addresses Disparities in Health Care,” Journal of the American Medical Association, July 2014 312(3):225–6.
No "Upcoding" Observed Among Hospitals with EHR Systems
A study that sought to determine whether hospitals were systematically using electronic health records to increase reimbursement by using billing codes that reflect more intensive care or a sicker patient population found no evidence that such upcoding was occurring. The researchers found that patient acuity and payment per discharge were essentially the same between hospitals that had adopted EHRs and those that hadn’t. They also found no evidence of increases in patient acuity or payment among hospitals that might be more likely to use EHRs to increase coding and revenue, such as for-profit hospitals and those operating in highly competitive markets. J. Adler-Milstein and A. J. Jha, “No Evidence Found That Hospitals Are Using New Electronic Health Records to Increase Medicare Reimbursements,” Health Affairs, July 2014 33(7):1271–7.
Variation in Treatment Common Among Cancer Centers for Some Conditions
A study of variation in treatment among 18 cancer centers for patients with breast cancer, colorectal cancer, lung cancer, or non-Hodgkin lymphoma found inter-institutional variation was high for 35 of 171 oncology management decisions, including nine of 22 (41%) decisions for non-Hodgkin lymphoma, 16 of 76 (21%) for breast cancer, seven of 47 (15%) for lung cancer, and three of 26 (12%) for colorectal cancer. Forty-six percent of high-variance decisions involved imaging or diagnostic procedures and 37 percent involved choice of chemotherapy regimen. The researchers concluded substantial variation in institutional practice among cancer centers reveals a lack of consensus about optimal management for common clinical scenarios and they suggest that providers pay particular attention to patient preferences when making management decisions with high variation. J. C. Weeks, H. Uno, N. Taback et al., “Interinstitutional Variation in Management Decisions for Treatment of 4 Common Types of Cancer: A Multi-institutional Cohort Study,” Annals of Internal Medicine, July 2014 161(1):20–30.
Having Both Meaningful Use and PCMH Certification Associated with Higher Quality
Researchers studying 14 primary care practices that achieved the first stage of meaningful use of electronic health records found only four practices used data consistently to assess their performance and only three reported improvements in care. Practices that were patient-centered medical homes (PCMHs) scored higher on all quality improvement domains and received financial rewards more commonly, suggesting that the formal alignment of meaningful use and PCMH criteria, combined with technical assistance to practices, may improve primary care quality. T. P. Meehan, Sr., T. P. Meehan, Jr., M. Kelvey-Albert et al., “Meaningful Use, Patient-Centered Medical Homes, Financial Incentives, and Technical Assistance,” American Journal of Medical Quality, July/August 2014 29(4):284–91.
Commentary: More Effort Needed to Reduce Hospital Readmissions
A commentary in the American Journal of Medical Quality considers several possible reasons the U.S. has made so little progress in reducing hospital readmission rates despite years of intense effort and the availability of evidence-based interventions. They note that adherence to the elements of successful interventions may be low and that efforts to improve care transitions have not fully engaged communities and patients. The extent to which institutions have established proper structures and processes to support optimal care transitions—such as the timely release of high-quality discharge summaries—is also unclear. Its authors recommend further research to identify effective structural and process changes associated with better performance, the factors associated with intervention fidelity, and best practices for engaging communities and patients. R. N. Axon and E. A. Coleman, “What Will It Take to Move the Needle on Hospital Readmissions?” American Journal of Medical Quality, July/August 2014 29(4):357–9.
Nine of Ten FQHCs Now Have EHR Systems
A study assessing the effects of meaningful-use incentive payments on adoption and use of electronic health records (EHRs) among federally qualified health centers (FQHCs) found that between 2010 (the year before incentive payments began) and 2012 (the second year of such payments) nine of 10 health centers adopted an EHR system. Half adopted EHRs with seven functions key to quality improvement, including the ability to maintain medication lists and prescribe electronically. Smaller centers and those with greater numbers of poor patients were less likely to have adopted EHRs. The researchers found that centers that met stage-one meaningful use requirements were twice as likely to be recognized in state or national quality programs. To promote greater adoption and use of EHRs, they recommend policies that provide technical assistance to FQHCs and leverage the connection between meaningful use and quality recognition programs. E. B. Jones and M. F. Furukawa, “Adoption and Use of Electronic Health Records Among Federally Qualified Health Centers Grew Substantially During 2010–12,” Health Affairs, July 2014 33(7):1254–61.
Commentary: Benefits of Hospital Consolidation Achievable Without Mergers
A commentary in the Journal of the American Medical Association challenges three common arguments in favor of hospital consolidation by pointing out the theoretical benefits of consolidation—improved quality through higher volume of services, better integration of care, and the potential for greater investment in quality improvement—can be achieved through alternate means. These methods include lowering payment for poor outcomes and tying payment incentives to longer-term outcomes. They also note that many of the large integrated systems that are cited to establish the benefits of consolidation achieved their higher performance though a longstanding commitment to quality rather than size. T. C. Tsai and A. K. Jha, “Hospital Consolidation, Competition, and Quality: Is Bigger Necessarily Better?” Journal of the American Medical Association, July 2014 312(1):29–30.
U.S. Makes Progress on Some Health Indicators, Backtracks on Others
An analysis of data from the Healthy People 2020 report card on the health of the nation found that in the first three years of this decade, there was notable improvement on 14 of 26 leading health indicators, including infant mortality, colorectal cancer screening, and childhood immunizations. On four indicators—including the percentage of adults meeting federal guidelines for aerobic physical activity and muscle-strengthening activity—the country achieved the 2020 goal. But the report card data also documented no improvement for 11 of the 26 measures, and for two of indicators—major depressive episodes among adolescents and suicides—outcomes worsened. H. K. Koh, C. R. Blakey, and A. Y. Roper, “Healthy People 2020: A Report Card on the Health of the Nation,” Journal of the American Medical Association, June 2014 311(24):2475–6.
Public Health Data Used to Reduce Costs, Improve Population Health in New York State
A commentary in the Journal of the American Medical Association describes the benefits of publicly releasing governmental survey, surveillance, and administrative data to track epidemiological trends, identify risk factors, and study the health care delivery system. The article provides examples of how this information has been used in New York State to improve health care quality, reduce costs, facilitate population health planning and monitoring, and empower health care consumers to make better choices and live healthier lives. E. G. Martin, N. Helbig, and N. R. Shah, “Liberating Data to Transform Health Care: New York’s Open Data Experience,” Journal of the American Medical Association, June 2014 311(24):2481–2.
Online Rankings of Surgical Quality Fail to Help Patients Distinguish Among Hospitals
A study designed to determine whether the surgical quality measures that Medicare reports on its Hospital Compare website provide a basis for patients to differentiate hospitals within their geographic region found they do not because those providing information on surgical site infection prevention generally performed well, with little variation among them. The authors conclude that measuring other processes of care, such as post-surgical wound care, may improve public reporting's ability to positively impact patient decision-making and recommend additional research. K.C. Safavi, F. Dai, T. A. Gilbertsen et al., “Variation in Surgical Quality Measure Adherence Within Hospital Referral Regions: Do Publicly Reported Surgical Quality Measures Distinguish Among Hospitals That Patients Are Likely to Compare?” Health Services Research, Aug. 2014 49(4):1108–20.
PCMH Implementation at VHA Produces Mixed Results
A study of the effects of patient-centered medical home (PCMH) implementation on primary care delivery in the Veterans Health Administration (VHA) found the implementation resulted in large changes in the structure of care but few changes in patient-level outcomes. The authors found that between July 2010 and June 2012 the percentage of primary care appointments occurring by telephone increased, as did the number of patients contacted within two days of hospital discharge. They did not see significant improvements in the percentage of primary care visits occurring within the three days of the requested date and they found no association between medical home implementation and rates of emergency department use. R. M. Werner, A. Canamucio, J. A. Shea et al., “The Medical Home Transformation in the Veterans Health Administration: An Evaluation of Early Changes in Primary Care Delivery,” Health Services Research, Aug. 2014 49(4):1329–47.
Benefits, Challenges of Using Big Data at a Large Academic Medical Center
This article describes the extensive and multifaceted efforts of Beth Israel Deaconess Medical Center, an academic medical center affiliated with Harvard University, to mine data to improve clinical care, education, and research. It also outlines the challenges facing data users, including issues of data quality, variation in data collection over time, the inconsistent use of standard medical terminology, patient privacy concerns, and the need for expert data navigators to create meaningful queries. J. D. Halamka, “Early Experiences with Big Data at an Academic Medical Center,” Health Affairs, July 2014 33(7):113–28.
