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.

  • October/November 2014 Issue
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Publications of Note

Pilot of Bundled Payment Program Fails in California

This article chronicles the unsuccessful pilot of a bundled payment program for orthopedic surgery in California and offers recommendations for overcoming the impediments to its success. The health plans, hospitals, ambulatory care centers, and physician organizations engaged in the Integrated Healthcare Association's Bundled Episode Payment and Gainsharing Demonstration had difficulty reaching consensus on bundle definitions and exclusions, delaying the program. Other barriers included disagreements about the assumption of risk, administrative burdens, and state regulatory uncertainty. Ultimately, a few contracts were signed, but there was insufficient volume to test hypotheses about the impact of bundled payment on quality and costs. The researchers recommend that among other things developers of bundled payment programs ensure providers have sufficient volume to stimulate administrative and clinical changes in practice, find acceptable methods for managing risk, and introduce "appropriateness" criteria to discourage overuse of bundled procedures by providers. M. S. Ridgely, D. de Vries, K. J. Bozic et al., "Bundled Payment Fails to Gain a Foothold in California: The Experience of the IHA Bundled Payment Demonstration," Health Affairs, Aug. 2014 33(8):1345–52.

Pharmacy-Based Intervention Improves Medication Adherence

A study of the Pennsylvania Project, a large-scale demonstration designed to evaluate the impact of a pharmacy-based intervention on adherence to five chronic disease medication classes found the intervention significantly improved the mean adherence for all medication classes, by for example 4.8 percent for oral diabetes medications and 3.1 percent for beta-blockers. Additionally, there was a significant reduction in per patient annual health care spending for patients taking statins ($241) and oral diabetes medications ($341). The pharmacists screened patients to identify those at risk for poor medication adherence and provided brief interventions (including the use of motivational interviewing) to people with an elevated risk. J. L. Pringle, A. Boyer, M. H. Conklin et al.,"The Pennsylvania Project: Pharmacist Intervention Improved Medication Adherence and Reduced Health Care Costs," Health Affairs, Aug. 2014 33(8):1444–52.

High Intensity Transitional Care Needed to Reduce Short-Term Readmissions

A study that examined whether transitional care interventions were associated with a reduction of readmission rates in the short term (30 days or less), intermediate term (31–180 days), and long term (181–365 days) found that transitional care was effective in reducing all-cause intermediate-term and long-term readmissions. But only high-intensity interventions seemed to be effective in reducing short-term readmissions. The findings, based on 26 randomized controlled trials in a variety of countries, suggest that to reduce short-term readmissions, transitional care should consist of high-intensity interventions that include care coordination by a nurse, communication between the primary care provider and the hospital, and a home visit within three days after discharge. K. J. Verhaegh, J. L. MacNeil-Vroomen, S. Eslami et al., "The CARE SPAN: Transitional Care Interventions Prevent Hospital Readmissions for Adults with Chronic Illnesses," Health Affairs, Sept. 2014 33(9):1531–39.

High Variation in Admissions from ED for Low-Mortality Conditions Found

A study that examined the variation in risk-standardized hospital admission rates from emergency departments and the relationship of this variation to inpatient mortality for the 15 most commonly admitted medical and surgical conditions found risk-standardized admission rates differed substantially across emergency departments (EDs). The variation ranged from 1.03-fold for sepsis to 6.55-fold for chest pain between the 25th and 75th percentiles of the visits. Conditions such as chest pain, soft tissue infection, asthma, chronic obstructive pulmonary disease, and urinary tract infection were low-mortality conditions that showed the greatest variation. The findings suggest that some of these admissions might not be necessary—and may represent opportunities to improve efficiency and reduce health spending. The authors note the data indicate that there may be sizeable savings to U.S. payers if differences in ED hospitalization practices could be narrowed among a few of these high-variation, low-mortality conditions. A. K. Sabbatini, B. K. Nallamothu, and K. E. Kocher, "Reducing Variation in Hospital Admissions from the Emergency Department for Low-Mortality Conditions May Produce Savings," Health Affairs, Sept. 2014 33(9):1655–63.

EHR Adoption by Hospitals Increases, Meaningful Use Certification Less So

A study of recent data from the American Hospital Association Annual Survey of Hospitals—IT Supplement found electronic health record (EHR) adoption among U.S. hospitals continues to rise steeply: 59 percent now have at least a basic EHR. However, small and rural hospitals continue to lag behind their better-resourced counterparts in large or urban hospitals. Most hospitals are able to meet many of the stage 2 meaningful-use criteria, but only 5.8 percent of hospitals are able to meet them all. The authors note that several criteria, including sharing care summaries with other providers and providing patients with online access to their data, will require attention from EHR vendors to ensure that the necessary functions are available. Meeting these criteria will also require additional effort from many hospitals to make certain that these functionalities are used. They also recommend policymakers consider new targeted strategies to ensure that all hospitals move toward meaningful use of EHRs. J. Adler-Milstein, C. M. DesRoches, M. F. Furukawa et al., "More Than Half of US Hospitals Have at Least a Basic EHR, But Stage 2 Criteria Remain Challenging for Most," Health Affairs, Sept. 2014 33(9):1664–71.

Solo Physicians and Specialists Lag Behind Other Physicians in Adopting EHRs

Using data from the 2009–13 Electronic Health Records (EHR) Survey, researchers found that in 2013, 78 percent of office-based physicians had adopted some type of EHR, and 48 percent had the capabilities required for a basic EHR system. They also found persistent gaps in EHR adoption, with physicians in solo practices and non–primary care specialties lagging behind others. In addition, physicians’ electronic health information exchange with other providers was limited, with only 14 percent sharing data with providers outside their organizations. They found that 30 percent of physicians routinely used capabilities for secure messaging with patients, and 24 percent routinely provided patients with the ability to view online, download, or transmit their health record. M.F. Furukawa, J. King, V. Patel et al., "Despite Substantial Progress in EHR Adoption, Health Information Exchange and Patient Engagement Remain Low in Office Settings," Health Affairs, Sept. 2014 33(9):1672–79.

Determining Progress in Reducing Hospital Admissions Not Clear-Cut 

A commentary in the Journal of General Internal Medicine describes the challenges of determining whether substantial investments by hospitals in reducing readmission rates are having the intended effect of lowering overall health care spending and improving outcomes for patients. While readmission rates appear to be declining, the reductions may reflect changes in coding patterns and the increasing use of outpatient observation stays, which do not count as index admissions or readmissions. Assuming readmissions are declining, they note it is unclear whether this has led to better quality—citing among many other factors one study that found mortality has declined for myocardial infarction and pneumonia, but increased for heart failure. Other measures of patient safety reveal inconsistent reductions. There may be greater opportunity to achieve savings and quality improvement by focusing investment in an enhanced primary care system. M. B. Rothberg and N. Vakharia, "Readmissions Are Decreasing—Is It Time to Celebrate?" Journal of General Internal Medicine, Oct. 2014 29(10):1322–24.

Improving Care for Patients with Chronic Conditions

This commentary summarizes federal initiatives designed to improve health outcomes and lower the costs of caring for patients with two or more concurrent, chronic conditions. These include accountable care initiatives, plans to reimburse providers for managing the care of these patients outside of a face-to-face visit, and funding to expand participation in Stanford University’s Chronic Disease Self-Management Program, as well as many other initiatives. The programs are keeping within a strategic framework, developed with private-sector input, that the U.S. Department of Health And Human Services outlined in its 2010 report, Strategic Framework on Multiple Chronic Conditions. The commentary's authors recommend accelerating these efforts through a variety of means, including HHS’ recently released data on chronic conditions among Medicare fee-for-service beneficiaries to identify specific populations and geographic areas in which more coordinated and comprehensive approaches to prevention and treatment may be beneficial. A. K. Parekh, R. Kronick, and M. Tavenner, "Optimizing Health for Persons with Multiple Chronic Conditions," Journal of the American Medical Association, Sept. 24, 2014 312(12):1199–1200.

Instrument for Surveying Homeless Patients About Care Developed

This article describes the content of and method of developing a questionnaire for homeless patients designed to assess the quality of care they receive in patient-centered medical homes. The 33-item Primary Care Quality-Homeless (PCQ-H) Instrument gathers information on the patient–clinician relationship, cooperation among clinicians, access and coordination, and homeless-specific needs. The authors note existing methods of assessing patient-centered medical homes—the Consumer Assessment of Healthcare Providers and Systems (CAHPS) and the Primary Care Assessment Survey (PCAS)—are potentially problematic in their application to patients who may be poorly rested or cognitively impaired because the risk of error or overload may be high. In specific, the concerns and aspirations likely to be important to homeless patients are likely to differ from the content of the CAHPS and PCAS queries. S. G. Kertesz, D. E. Pollio, R. N. Jones et al., "Development of the Primary Care Quality-Homeless (PCQ-H) Instrument: A Practical Survey of Homeless Patients’ Experiences in Primary Care," Medical Care, Aug. 2014 52(8):734–42.

The Progress Made by Hospital Engagement Networks Questioned

This authors of this commentary in the New England Journal of Medicine say it is impossible to tell whether the Partnership for Patients Program—an estimated $1 billion initiative funded by the Centers for Medicare and Medicaid Services (CMS) to help hospitals reduce harms and readmissions in hospitals—worked because of the lack of rigor in CMS’ study design and the program’s evaluation, which did not include external peer review. CMS has touted the program’s success in reducing early elective deliveries and the national rate of all-cause readmissions. The authors say that among other problems the program did not use controls to measure improvement, allowed wide variation in measurement techniques including the use of process measures of unknown validity, and employed other design methods that are highly subject to bias. P. Pronovost and A. K. Jha, "Did Hospital Engagement Networks Actually Improve Care?" New England Journal of Medicine, Aug. 21, 2014 371(8):691–93.

Hospitals in Study of P4P Program Fail to Demonstrate Consistent Improvement Relative to Controls

A study of Advancing Quality, a pay-for-performance (P4P) program introduced in all hospitals in the northwest region of England in 2008, found that the observed short-term reductions (the first 18 months) in mortality for conditions linked to financial incentives in hospitals were not maintained. Researchers found that throughout the short-term and long-term (the next 24 months) periods, the performance of hospitals in the incentive program continued to improve and mortality for the three conditions covered by the program continued to fall. However, the reduction in mortality among patients with these conditions was greater in the control hospitals than in the hospitals that were participating in the program by 0.7 percentage points. By the end of the 42-month follow-up period, the reduced mortality in the participating hospitals was no longer significant (−0.1 percentage points). The researchers also noted that from the short term to the longer term, mortality rates for conditions not covered by the program fell more in the participating hospitals than in the control hospitals (by 1.2 percentage points), raising the possibility of a positive spillover effect on care for conditions not covered by the program. S. R. Kristensen, R. Meacock, A. J. Turner et al., "Long-Term Effect of Hospital Pay for Performance on Mortality in England,"New England Journal of Medicine, Aug. 7, 2014 371(6):540–8.

The Challenges of Controlling Waste in Health Care

A commentary in the New England Journal of Medicine describes current approaches to reducing the overuse of medical services—including interventions that use cost-sharing, financial incentives, and share decision-making tools to reduce consumer demand, as well as interventions that rely on risk sharing and decision support to alter provider behavior. The author notes the benefits and drawbacks of these and other approaches and suggests the most effective approaches may be those that combine partial capitation or shared savings with meaningful outcomes monitoring and quality measurement. Greater use of patient decision aids, clinical decision support, and clinician education and feedback is also recommended. C. H. Colla, "Swimming Against the Current—What Might Work to Reduce Low-Value Care?" New England Journal of Medicine, Oct. 2, 2014 371(14):1280–83.

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