Principles for a Pay-for-Outcomes System for Inpatient Care
To provide a foundation for developing a practical and effective payment system that rewards hospitals for achieving desired health outcomes rather than adhering to process-of-care guidelines, the authors of this article suggest eight guiding principles. Among others, they include: focusing on outcomes for which a quality failure results in an increase in payment; using financial incentives that are substantial enough to induce behavioral change; basing outcome standards on empirically derived performance levels that have been achieved by best-performing hospitals; and adjusting performance measures to account for a patient's severity of illness. R. F. Averill, J. S. Hughes, and N. I. Goldfield, "Paying for Outcomes, Not Performance: Lessons from the Medicare Inpatient Prospective Payment System," Joint Commission Journal on Quality and Patient Safety, April 2011 37(4):184–92.
Palliative Care Reduces Time and Costs of Intensive Care
Researchers studying the effect of palliative care team consultations on hospital costs for patients enrolled in Medicaid at four New York State hospitals found that on average patients who received palliative care incurred $6,900 less in hospital costs during a given admission than a matched group of patients who received usual care. These reductions included $4,098 in hospital costs per admission for patients discharged alive, and $7,563 for patients who died in the hospital. Palliative care recipients spent less time in intensive care, were less likely to die in intensive care units, and were more likely to receive hospice referrals than the matched usual care patients. R. S. Morrison, J. Dietrich, S. Ladwig et al., "The Care Span: Palliative Care Consultation Teams Cut Hospital Costs for Medicaid Beneficiaries," Health Affairs, March 2011 30(3):454–63.
Ability of Providers to Predict Readmissions Poor
A study designed to evaluate how well physicians, case managers, nurses, and a standardized risk tool predict whether their older patients would be readmitted to the hospital found that providers' ability to do so was poor, as was the accuracy of the risk tool. Physicians' mean readmission predictions were closest to the actual readmission rate, while case managers and nurses overestimated the number of likely readmissions. The study, which also found overall readmission rates were higher than previously reported, concluded that hospitals do not have accurate predictive tools to identify patients at the highest risk of readmission. N. Allaudeen, J. L. Schnipper, E. J. Orav et al., "Inability of Providers to Predict Unplanned Readmissions," Journal of General Internal Medicine, Online article March 11, 2011.
Medical Home Demonstration Identifies Obstacles to Team-Based Care
A report on the nation's first national medical home demonstration found the process of transforming 36 mostly small independent practices into medical homes was lengthy and complex. Practices were successful in implementing discrete components of the model that could be adopted with minimal impact on individual roles and other practice processes, but encountered difficulty when implementing components that required fundamental changes in established routines and coordination across workgroups. P. A. Nutting, B. E. Crabtree, W. L. Miller et al., "Transforming Physician Practices to Patient-Centered Medical Homes: Lessons from the National Demonstration Project," Health Affairs, March 2011 30(3):439–45.
Low Nursing Levels Associated with Increased Mortality
A study that relied on data from a large tertiary academic medical center found there was a significant association between increased mortality rates and increased exposure to shifts during which staffing by registered nurses was eight hours or more below the target level. The association between increased mortality and high patient turnover was also significant. J. Needleman, P. Buerhaus, S. Pankratz et al., "Nurse Staffing and Inpatient Hospital Mortality," New England Journal of Medicine, March 2011 364(11):1037–45.
Higher Spending Linked to Lower Inpatient Mortality
Researchers studying the association between hospital spending and risk-adjusted inpatient mortality in California hospitals found that for each of six diagnoses on admission—acute myocardial infarction, heart failure, acute stroke, gastrointestinal hemorrhage, hip fracture, and pneumonia—patient admission to higher-spending hospitals was associated with lower risk-adjusted inpatient mortality rates. The association between hospital spending and inpatient mortality did not vary by region or hospital size. J. A. Romley, A. B. Jena, D. P. Goldman et al., "Hospital Spending and Inpatient Mortality: Evidence from California: An Observational Study," Annals of Internal Medicine, Feb. 2011 154(3):160–67.
Racial Disparities Evident in Hospital Readmission Rates
A study designed to determine whether black patients have higher odds of readmission than white patients and whether these disparities are related to where black patients receive care found that, overall, black patients had higher readmission rates than white patients (24.8% vs. 22.6%) and that patients from hospitals serving disproportionate numbers of minority patients had higher readmission rates than those from hospitals that do not (25.5% vs. 22.0%). Among patients with acute myocardial infarction, black patients from hospitals serving disproportionate numbers of minority patients had the highest readmission rate (26.4%). Patterns were similar among those with heart failure and pneumonia. The results were unchanged after adjusting for hospital characteristics, including markers of caring for poor patients. K. E. Joynt, E. J. Orav, and A. K. Jha, "Thirty-Day Readmission Rates for Medicare Beneficiaries by Race and Site of Care," Journal of the American Medical Association, Feb. 2011 305(7):675–81.
Commentary Urges CMS to Use Caution in Holding Hospitals Accountable for Readmission Rates
A commentary published in the Journal of the American Medical Association outlined some of the challenges of using hospital readmissions as a proxy for poor-quality inpatient and outpatient care and poor care transitions. It also urged the Centers for Medicare and Medicaid Services (CMS) to use caution when adjusting payments to hospitals according to their rate of excess or expected Medicare readmissions for pneumonia, acute myocardial infarction, and heart failure, which CMS will begin doing in 2013. The authors also expressed concern about the validity of measures used to identify preventable readmissions and recommended that CMS develop process-of-care measures that document adherence to evidence-based practices such as high-quality medication reconciliation, telephone follow-up, or use of nurse-directed case management services. They also recommend making adjustments to ensure that hospitals caring for a high proportion of minority or economically disadvantaged patients are not unfairly punished by the proposed value-based payment program based on readmission rates. R. N. Axon and M. V. Williams, "Hospital Readmission as an Accountability Measure," Journal of the American Medical Association, Feb. 2011 305(5):504–5.
Community-Based Program Reduces Hospital Admissions for Heart Disease
A community-based health promotion and prevention program in Canada that invited residents ages 65 or older to attend volunteer-run cardiovascular risk assessment and education sessions held in local pharmacies over a 10-week period resulted in 3.02 fewer annual hospital admissions for cardiovascular disease per 1,000 people. As part of the program, automated blood pressure readings and self-reported risk factor data were collected and shared with participants and their family physicians and pharmacists. Statistically significant reductions favoring the intervention communities were seen in hospital admissions for acute myocardial infarction and heart failure, but not for stroke. J. Kaczorowski, L. W. Chambers, L. Dolovich et al., "Improving Cardiovascular Health at Population Level: 39 Community Cluster Randomised Trial of Cardiovascular Health Awareness Program (CHAP)," BMJ, published online Feb. 7, 2011.
Authors Caution ACOs Pose a Monopoly Hazard
This commentary published in the Journal of the American Medical Association outlined the authors' concerns that accountable care organizations (ACOs) that join competing health care organizations may have dangerous market power and deserve heightened—and not relaxed—antitrust attention. The authors argue that ACOs should be allowed to integrate organizations vertically, but horizontal combinations should not be allowed unless affected submarkets have an ample number of effective competitors. The commentary suggests that antitrust authorities or Medicare should impose a preapproval process to prevent the formation of ACOs that concentrate market power. Medicare should also require ACOs to meet national standards of efficiency in serving private and Medicare patients, they say. B. D. Richman and K. A. Schulman, "A Cautious Path Forward on Accountable Care Organizations," Journal of the American Medical Association, Feb. 2011 305(6):602–3.
Mortality Rates Reduced by Initiative to Cut Hospital-Acquired Infections
An evaluation of the Michigan Keystone ICU project, a comprehensive statewide quality improvement initiative focused on reduction of hospital-acquired infections, found the program was associated with a significant decrease in hospital mortality rates in Michigan, compared with the surrounding area. Reductions in mortality were significantly greater for the study group (95 hospitals) than for the comparison group (364 hospitals) up to 22 months after the implementation of the project. Length of stay did not differ significantly between the groups. A. Lipitz-Snyderman, D. Steinwachs, D. M. Needham et al., "Impact of a Statewide Intensive Care Unit Quality Improvement Initiative on Hospital Mortality and Length of Stay: Retrospective Comparative Analysis," BMJ, published online Jan. 31, 2011.
Education and Auditing Help to Reduce Hospital-Acquired Infections
To determine the effectiveness of a quality improvement program designed to increase delivery of evidence-based practices in intensive care units (ICUs), researchers introduced audit and feedback tools and expert-led education sessions. The greatest improvement was in the use of a practice to prevent ventilator-associated pneumonia—semi-recumbent positioning (90% of patient days in the last month of the intervention versus 50% in the first month)—and the use of precautions to prevent catheter-related bloodstream infections. Providers adhered to all seven components of the catheter insertion bundle for 70 percent of patients receiving central lines in the last month of the intervention versus 10 percent in the first month. Adoption of other practices changed little. D. C. Scales, K. Dainty, B. Hales et al., "A Multifaceted Intervention for Quality Improvement in a Network of Intensive Care Units: A Cluster Randomized Trial," Journal of the American Medical Association, Jan. 2011 305(4):363–72.