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Publications of Note

High Nurse Staffing Levels Associated with Lower Rates of 30-Day Readmissions

A study that sought to determine the relationships between hospital nurses' work environment, education, and staffing levels and 30-day readmission rates among Medicare patients undergoing general, orthopedic, and vascular surgery found that higher nurse staffing ratios and better work environments were significantly associated with lower 30-day readmissions. The survey, which included information on 220,914 Medicare surgical patients and 25,082 nurses from 528 hospitals in four states, found that the average 30-day readmission rate was 10 percent. Readmission rates varied widely across surgical procedures and could be as high as 26 percent for upper limb and toe amputation for circulatory system disorders. Each additional patient per nurse increased the odds of readmission by 3 percent. Patients cared for in hospitals with better nurse work environments had lower odds of readmission. Administrative support to nursing practice and nurse–physician relationships were two main attributes of the work environment that were associated with readmissions. C. Ma, M. D. McHugh, and L. H. Aiken, “Organization of Hospital Nursing and 30-Day Readmissions in Medicare Patients Undergoing Surgery,” Medical Care, Jan. 2015 53(1):65–70.

Patients from Disadvantaged Neighborhoods Have Higher 30-Day Readmission Rates

Researchers found that among Medicare patients discharged with congestive heart failure, pneumonia, or myocardial infarction, residing within a disadvantaged neighborhood was a predictor of readmission. They found 30-day readmission rates did not vary significantly across least disadvantaged neighborhoods, which had an average readmission rate of 21 percent. However, within the most disadvantaged 15 percent of neighborhoods, readmissions increased from 22 percent to 27 percent as the measure of disadvantage—calculated via a scale known as the area deprivation index (ADI)—worsened. The authors suggest using measures of neighborhood disadvantage, such as ADI, could be used to inform policy and care after hospital discharge. A. J. H. Kind, S. Jencks, J. Brock et al., “Neighborhood Socioeconomic Disadvantage and 30-Day Rehospitalization: A Retrospective Cohort Study,” Annals of Internal Medicine, Dec. 2014 161(11):765–74.

Racial Disparities in Outcomes for Medicare Advantage Enrollees Persist for Chronic Conditions

A study of enrollees in Medicare Advantage plans found that black enrollees in 2006 and 2011 were substantially less likely than white enrollees to have adequate control of blood pressure, cholesterol, and HbA1c. These differences persisted in 2011 in the Northeast, Midwest, and South but were eliminated in the West for all three measures. Hispanic enrollees were less likely than whites in 2011 to have adequate control of blood pressure, cholesterol, and HbA1c. Asians and Pacific Islanders were more likely than whites to have adequate control of blood pressure and cholesterol and had similar control of HbA1c. J. Z. Ayanian, B. E. Landon, J. P. Newhouse et al., “Racial and Ethnic Disparities Among Enrollees in Medicare Advantage Plans,” New England Journal of Medicine, Dec. 2014 371(24):2288–97.

Quality and Equity Improve for Inpatient Care

A study of publicly reported quality measures for patients who were hospitalized for acute myocardial infarction, heart failure, or pneumonia found improved performance on quality measures for white, black, and Hispanic adults and increased racial and ethnic equity in performance rates both within and among U.S. hospitals. Adjusted performance rates for the 17 quality measures improved by 3.4 to 57.6 percentage points from 2005 to 2010 for white, black, and Hispanic adults. In 2005, as compared with adjusted performance rates for white patients, adjusted performance rates were more than 5 percentage points lower for black patients on three measures and for Hispanic patients on six. The authors note that decreasing differences according to race or ethnic group were attributable to more equitable care for white patients and minority patients treated in the same hospital, as well as to greater performance improvements among hospitals that disproportionately serve minority patients. A. N. Trivedi, W. Nsa, L. R. M. Hausmann et al., “Quality and Equity of Care in U.S. Hospitals,” New England Journal of Medicine, Dec. 2014 371(24):2298–308.

Health Coaching Reduces Spending for High-Risk Patients

A study of health coaching interventions for high-risk patients looked at the effect they had on inpatient, emergency department, outpatient, and prescription drug expenditures. It found that although the probability of incurring costs and expenditure levels for emergency services were not affected, the probability of incurring inpatient expenditures and levels of outpatient and total costs for health coaching participants fell significantly relative to controls. The estimated outpatient and total cost savings were $286 and $412 per person per month, respectively. Y. Jonk, K. Lawson, H. O’Connor et al., “How Effective Is Health Coaching in Reducing Health Services Expenditures?” Medical Care, Feb. 2015 53(2):133–40.

A New Vision for Quality Measurement

The authors of this commentary offer an alternative vision for quality measurement, one that addresses concerns that existing measurement techniques are burdensome and inaccurate and fail to capture what matters most to patients. Their recommendations reflect the view that quality measurement should be integrated with care delivery rather than operating in parallel, that it should acknowledge and address the challenges providers face with respect to diagnosis and treatment, and that it factor in the preferences and goals of patients. The measurement tools should capture a comprehensive inventory of each patient’s health and health care needs, include a mechanism for matching potential evidence-based interventions to those needs, and assess patients’ health goals and preferences. The authors say this would allow for the development of a proactive care plan for each patient from which an individualized quality score could be derived. E. A. McGlynn, E. C. Schneider, and E. A. Kerr, “Reimagining Quality Measurement,” New England Journal of Medicine, Dec. 2014 371(23):2150–53.

Developing Quality Measures That Assess the Care of Patients with Multiple Chronic Conditions

The authors of this article describe three mechanisms by which the Centers for Medicare and Medicaid Services (CMS) could transform quality measurement into a process that supports clinicians caring for patients with multiple chronic conditions. The policy opportunities include: 1) creating a framework to assess care for patients with multiple, rather than single, chronic diseases; 2) using common performance measures for individual clinicians, hospitals, and communities to accelerate meaningful improvement in the prevention and management of chronic conditions across local populations; and 3) using longitudinal measurement as a foundation for sustained quality improvement. A. Venkatesh, K. Goodrich, and P. H. Conway, “Opportunities for Quality Measurement to Improve the Value of Care for Patients with Multiple Chronic Conditions,” Annals of Internal Medicine, Nov. 2014 161(10 Suppl.):S76–S80.

Use of Surgical Checklists Does Not Improve Outcomes or Reduce Costs

A study of the Keystone Surgery project—which involved implementation of an evidence-based checklist and Comprehensive Unit–based Safety Program across Michigan—found that it was not associated with improved surgical outcomes or reduced costs. The study found no differences in adjusted rates of 30-day mortality, complications, reoperations, or readmissions when compared with a national cohort of nonparticipating hospitals. The study also found Medicare payments for the index admission increased following implementation by $516 on average, as did readmission payments. B. N. Reames, C. P. Scally, J. R. Thumma et al., “Evaluation of the Effectiveness of a Surgical Checklist in Medicare Patients,” Medical Care, Jan. 2015 53(1):87–94.

Collaboration Among Hospitalists and PCPs Needed

The authors of this commentary recommend instituting a collaborative inpatient care model that incorporates a patient’s primary care provider (PCP) as a consultant on hospitalist teams as a means of improving communication and continuity of care. Under such a voluntary system, which could occur through in-person interactions or telehealth tools, primary care providers would visit their hospitalized patients within 12 to 18 hours of admission to highlight key elements of their medical history and make recommendations and would return on an as-needed basis and just before discharge. Instituting such a program would require new payment methodologies, but the authors suggest any additional costs could be offset by improved diagnostic efficiency and accuracy, reduced lengths of stay, and reductions in unnecessary testing, preventable readmissions, and inappropriate discharge. A. H. Goroll and D. P. Hunt, “Bridging the Hospitalist–Primary Care Divide Through Collaborative Care,” New England Journal of Medicine, Jan. 22, 2015 372(4):308–9.

Cellphone and Tablet Technology Used in Huddles Reduces Length of Stay, Improves Follow-Up Care for Stroke Patients

A neurology stroke service that instituted a multidisciplinary discharge huddle, augmented with cellular and tablet technology, decreased length of stay for stroke patients at its medical center by 1.4 days or 25 percent, and increased patient flow to partner organizations by 10 percent, while reducing the number of patients going without services after their hospital stay by more than 12 percent. Huddle members reported that the technology was helpful, heavily utilized, and made their work more efficient. The medical center has since expanded the model to its neurosurgery, neurology, cardiology, and trauma services, among others. B. R. Tielbur, D. E. Rice Cella, A. Currie et al., “Discharge Huddle Outfitted with Mobile Technology Improves Efficiency of Transitioning Stroke Patients into Follow-Up Care,” American Journal of Medical Quality, Jan./Feb. 2015 30(1):36–44.

HIT Improves Information Sharing But Gaps Remains

A study designed to measure the extent to which office-based physicians receive patient health information necessary to coordinate care across settings found that in 2012, 64 percent of physicians routinely received the results of a patient’s consultation with a provider outside of their practice, whereas 46 percent routinely received a patient’s history and reason for a referred consultation from a provider outside of their practice. About 54 percent of physicians reported routinely receiving a patient’s hospital discharge information. The study also sought to determine whether receipt of information needed to coordinate care is associated with use of health information technology (HIT). Physicians using an electronic health record system who shared patient health information electronically were more likely to receive the results of outside consultations or patient’s history and reason for a referred consultation. No significant differences were observed for the receipt of hospital discharge information by use of HIT. The authors note that while a higher percentage of physicians using HIT received patient information necessary for care coordination than those who did not use HIT, more than one-third did not routinely receive the needed patient information at all. C. J. Hsiao, J. King, E. Hing et al., “The Role of Health Information Technology in Care Coordination in the United States,” Medical Care, Feb. 2015 53(2):184–90.

Encouraging Collaboration Among Providers and Communities to Improve Outcomes

The authors of this commentary recommend developing methods of linking the delivery system, the community, and the patient in an integrated effort to improve population health. One means of doing this is to begin reporting and acting on clinical performance measures at the community level rather than at the level of delivery system units such as hospitals or physicians. This would enable identification of patients residing in communities where quality of care and outcomes are unsatisfactory, the identification of promising approaches, and the integration of these approaches into the care plans of patients. They also recommend finding positive outliers among patients in these communities and encouraging collaboration among them and primary care providers to develop new strategies for addressing the challenges patients face. They note this approach will probably be most successful in large, integrated delivery systems with large patient populations, but say smaller delivery systems might collaborate with payers to obtain the data they need. T. D. Sequist and E. M. Taveras, “Clinic–Community Linkages for High-Value Care,” New England Journal of Medicine, Dec. 2014 371(23):2148–50.

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