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 2014 Issue
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Publications of Note

Patient Preferences Explain Some Variation in Medicare Spending at the End of Life But Less Before
A study of regional variations in traditional fee-for-service Medicare spending found that patient preferences explained only 5 percent of the variation across hospital referral regions (HRRs). In comparison, supply factors—such as the number of physicians, specialists, and hospital beds—accounted for 23 percent of the variation, and patients' health and income explained 12 percent. The authors also studied the impact of patient preferences on spending for end-of-life care and physician services and found patient preferences explained a significant share of variation in spending among HRRs for end-of-life care, but explained only a small share of variation in spending on physician services. The authors recommend that policymakers consider both supply factors and patient preferences in deciding how much to accommodate area variation in spending. L. C. Baker, M. K. Bundorf, and D. P. Kessler, "Patients' Preferences Explain a Small But Significant Share of Regional Variation in Medicare Spending," Health Affairs, June 2014 33(6):957–63.

Use of Patient-Centered Medical Home Model in the VHA Produces Modest Improvements
Researchers studying an initiative by the Veterans Health Administration (VHA) to implement patient-centered medical homes across the delivery system was associated with modest increases in the number of primary care visits and with modest decreases in both hospitalization rates for ambulatory care–sensitive conditions and the number of outpatient visits with mental health specialists. They estimate that these changes avoided $596 million in costs, compared with the investment in PACT of $774 million, producing a potential net loss of $178 million. They conclude that while PACT has not yet generated a positive return, it is still maturing and trends in costs and use are favorable. P. L. Hebert, C.-F. Liu, E. S. Wong et al., "Patient-Centered Medical Home Initiative Produced Modest Economic Results for Veterans Health Administration, 2010–12," Health Affairs, June 2014 33(6):980–87.

Though Not Currently a Major Focus of ACOs, Surgical Care May Soon Be
A study of the early experience of 59 Medicare-approved accountable care organizations (ACOs) found that they had so far devoted little attention to surgical care even though surgeons and other specialists play an important role in determining health care costs. Instead the ACOs focused on coordinating care for patients with chronic conditions and reducing avoidable hospital admissions and emergency department visits. The authors predict the ACOs will likely focus on surgical care in the future but may face challenges in markets where it is difficult to influence surgeons' behavior. J. M. Dupree, K. Patel, S. J. Singer et al., "Attention to Surgeons and Surgical Care Is Largely Missing from Early Medicare Accountable Care Organizations, Health Affairs, June 2014 33(6):972–79.

A Modified Version of Human Factors Analysis May Be Superior to Root Cause Analyses in Reducing Medical Errors
The authors of this article recommend using a modified version of the Human Factors Analysis Classification System to analyze the cause of medical errors because it offers a much more precise classification of error than the Root Cause Analysis (RCA) method, which the authors say is flawed because results are neither standardized nor reliable across organizations and it leads hospitals to focus on the "who" and "what" rather than "why" the error occurred. They also note that when using RCAs, identified causes of medical errors are often not specific enough to develop actionable corrective plans and that a standardized nomenclature does not exist to allow analysis of recurring errors across the organization. T. Diller, G. Helmrich, S. Dunning et al., "The Human Factors Analysis Classification System (HFACS) Applied to Health Care," American Journal of Medical Quality, May/June 2014 29(3):181–90.

Mayo Finds Two-Thirds of Its Cardiac Surgery Patients Would Benefit from Uniform Care
By mapping the care process, segmenting the patient population, using information technology to communicate clearly defined expectations, and empowering nonphysician providers at the bedside, the Mayo Clinic was able to reduce variation in care delivered to cardiac surgery patients, which, in turn, reduced resource use, length of stay, and cost. Mayo found the uniform or "factory focused" approach was appropriate for 67 percent of patients. For the others, a "solution shop" approach, which relies on expert physicians to determine the course of care, was more appropriate. D. Cook, J. E. Thompson, E. B. Habermann et al., "From 'Solution Shop' Model to 'Focused Factory' in Hospital Surgery: Increasing Care Value and Predictability," Health Affairs, May 2014 33(5):746–55.

Eliminating Copays Reduces Outcomes Disparities Between White and Nonwhite Patients Taking Medication Following Myocardial Infarction
A study that sought to determine the impact of a program that eliminated copayments for medication following myocardial infarction found it increased medication adherence among white and nonwhite patients and had a dramatic impact on outcomes for nonwhite patients, including African Americans and Hispanics, who are 10 percent to 40 percent less likely than whites to receive secondary prevention therapies. The researchers found among nonwhite patients, the program reduced the rates of major vascular events or revascularization by 35 percent and reduced total health care spending by 70 percent. Providing full coverage had no effect on clinical outcomes and costs for white patients. N. K. Choudhry, K. Bykov, W. H. Shrank et al., "Eliminating Medication Copayments Reduces Disparities in Cardiovascular Care," Health Affairs, May 2014 33(5):863–70.

Care Transitions Intervention Produces Significant Cost Savings
An analysis of the impact of the Care Transitions Intervention found the model, which helps patients being discharged from a hospital to their homes manage their health, found it led to significantly lowered utilization of health care services (such as hospitalizations post discharge, outpatient physician services, and postacute care, including home health visits) in the six months after hospital discharge among Medicare beneficiaries in Rhode Island. Compared with controls, the intervention group also had lower mean total health care costs ($14,729 vs. $18,779). Shifting of costs to other utilization types, such as emergency department use, was not observed. R. Gardner, Q. Li, R. R. Baier et al., "Is Implementation of the Care Transitions Intervention Associated with Cost Avoidance After Hospital Discharge?" Journal of General Internal Medicine, June 2014 29(6):878–84.

Poverty and Population Health Indices May Be Superior to CMS' Method of Adjusting for Health Risk
The authors of this study found health risk adjustment using either the poverty index or the population health index performed substantially better in terms of explaining actual mortality rates than did indices that relied on diagnosis codes in administrative databases. They found the population health index explained the majority of variation in age-, sex-, and race-adjusted mortality. In contrast, the Hierarchical Condition Categories (HCC) index used by the Centers for Medicare and Medicaid Services (CMS), which depends on diagnoses listed in administrative databases, explained less that 5 percent of the variation in age-, sex-, and race-adjusted mortality; increased rather than reduced variation; and resulted in "implausible" swings in mortality rates in regions with high and low levels of physician visits per capita. D. E. Wennberg, S. M. Sharp, G. Bevan et al., "A Population Health Approach to Reducing Observational Intensity Bias in Health Risk Adjustment: Cross Sectional Analysis of Insurance Claims," BMJ, April 2014 348:g2392.

Diabetes Complications Drop Over Two Decades While Prevalence of Disease Increases
An examination of trends in the incidence of diabetes-related complications in the U.S. over the past two decades looked at incidences of lower-extremity amputation, end-stage renal disease, acute myocardial infarction, stroke, and death from hyperglycemic crisis and found that rates of all complications declined during this period, with the largest relative declines in acute myocardial infarction (−67.8%) and death from hyperglycemic crisis (−64.4%), followed by stroke (−52.7%) and amputations (−51.4%). The smallest decline was in end-stage renal disease (−28.3%). The authors note a large burden of disease persists because of the continued increase in the prevalence of diabetes. E. W. Gregg, Y. Li, J. Wang et al., "Changes in Diabetes-Related Complications in the United States, 1990–2010," New England Journal of Medicine, April 17, 2014 370(16):1514–23.

Transforming Specialty Care Practice Key to Delivery System Redesign
A commentary in the New England Journal of Medicine notes that while efforts to reduce fragmentation of care and cost have focused heavily on primary care practices, they account for only 6 percent of health care spending. To have a significant influence, such efforts must engage specialists more fully in building systems that ensure timely access and improved care coordination, as well as appropriate utilization of specialty care services and management of high-risk populations. The authors point to different models, including the use of "patient-centered specialty practices," that are fashioned after patient-centered medical homes (PCMHs). They also describe the concept of a "medical neighborhood," which attempts to align PCMHs with specialty care practices, ancillary service providers, and hospitals. The latter require aligned information architecture, an organizational culture that supports shared learning and transparency of performance and cost data among participating practices, and payment incentives that are aligned around shared accountability for outcome and cost. X. Huang and M. B. Rosenthal, "Transforming Specialty Practice—The Patient-Centered Medical Neighborhood," New England Journal of Medicine, April 10, 2014 370(15):1376–79.

Long-Term Care Setting for Dual Eligibles Affects Probability of a Potentially Preventable Hospitalization
Elderly Medicaid beneficiaries receiving home and community-based services (HCBS) have a higher probability of experiencing a potentially preventable hospitalization (PPH) than do nursing home residents, according to a study of beneficiaries eligible for both Medicare and Medicaid. In both groups, the most frequent conditions accounting for PPHs were the same: congestive heart failure, pneumonia, chronic obstructive pulmonary disease, urinary tract infection, and dehydration. But compared with nursing home residents, elderly HCBS users had an increased probability of experiencing both a PPH and a non-PPH. A. Wysocki, R. L. Kane, E. Golberstein et al., "The Association Between Long-Term Care Setting and Potentially Preventable Hospitalizations Among Older Dual Eligibles," Health Services Research, June 2014 49(3):778–97.

Recommended Prescribing After Myocardial Infarction Drops Off One Year After a Quality Improvement Intervention
A study in five hospitals of the American College of Cardiology's Guideline Applied to Practice (GAP) quality improvement initiative, designed to encourage physician adherence to recommended medication prescribing and other guidelines for treatment of acute myocardial infarction, found an increase in early administration of beta-blockers a full year after implementation (87.9% a year after the intervention was completed vs. 72.1% immediately after the initiative). However, prescriptions for aspirin (83% vs. 90%) and beta blockers (84% vs. 92%) dropped. Predictors of receiving appropriate medications were male gender (for aspirin and beta-blockers) and treatment with percutaneous coronary intervention compared with coronary artery bypass graft. The authors conclude that additional strategies for improving sustainability of quality improvement efforts are needed. A. B. Olomu, M. Stommel, M. M. Holmes-Rovner et al., "Is Quality Improvement Sustainable? Findings of the American College of Cardiology's Guidelines Applied in Practice," International Journal for Quality in Health Care, June 2014 26(3):215–22.

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