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Publications of Note

Mortality Rates Linked to Inability to Effectively Rescue Patients from Complications
A study that sought to determine whether increased mortality rates at low-volume hospitals were due to higher complication rates or less success in rescuing patients from complications found that differences in mortality between high- and low-volume hospitals are not associated with large differences in complication rates. Instead, these differences seem to be associated with the ability of a hospital to effectively rescue patients from complications. The authors of the study—which focused on patients undergoing three high-risk cancer operations: gastrectomy, pancreatectomy, and esophagectomy—concluded that strategies focusing on the timely recognition and management of complications once they occur may be essential to improving outcomes at low-volume hospitals. A. A. Ghaferi, J. D. Birkmeyer, and J. B. Dimick, “Hospital Volume and Failure to Rescue with High-Risk Surgery,” Medical Care, Dec. 2011 49(12):1076–81.

Leapfrog Safe Practices Survey Not Linked to Major Surgery Mortality Rates
A study that sought to determine whether hospital compliance with the National Quality Forum Patient Safety Practices was associated with improved outcomes did not find evidence that patients undergoing major surgery at hospitals with higher scores had lower mortality rates. It also found the use of computerized physician order entry and intensive care units’ physician staffing levels were not associated with hospital mortality. The study concluded that the scores, which are reported in the Leapfrog Safe Practices Survey, may have limited power to distinguish between high-quality and low-quality hospitals. F. Qian, S. J. Lustik, C. A. Diachun et al., “Association Between Leapfrog Safe Practice Score and Hospital Mortality in Major Surgery,” Medical Care, Dec. 2011 49(12):1082–88.

Capitation Arrangements Lower Costs, Intensity of Care
A study that examined the relationship between primary care physicians' (PCPs) payment arrangements and the total costs and intensity of care for specific episodes of care for Medicare beneficiaries found that physicians in highly capitated practices had the lowest total costs and intensity of care, suggesting that these physicians develop an overall approach to care that also applies to their fee-for-service patients. B. E. Landon, J. D. Reschovsky, A. J. O’Malley et al., “The Relationship Between Physician Compensation Strategies and Intensity of Care Delivered to Medicare Beneficiaries,” Health Services Research Dec. 2011 46(6):1863–82.

Fewer Coordination Failures, Medical Errors in Countries That Rely on Medical Homes for Adults with Complex Care Needs
In 10 countries surveyed, patients who have a medical home reported better coordination of care, fewer medical errors, and greater satisfaction with care than those without one. Sicker adults in the U.S. stood out for having cost and access problems. More than one of four (27%) were unable to pay or encountered serious problems paying medical bills in the past year, compared with between 1 percent and 14 percent of adults in the other countries. In the U.S., 42 percent reported not visiting a doctor, not filling a prescription, or not getting recommended care. This is twice the rate for every other country but Australia, New Zealand, and Germany. C. Schoen, R. Osborn, D. Squires et al., “New 2011 Survey of Patients with Complex Care Needs in Eleven Countries Finds That Care Is Often Poorly Coordinated,” Health Affairs, published online Nov. 9, 2011.

Safety Attitudes Questionnaire Action Plan Lowers Hospital-Acquired Infection Rates
A study designed to evaluate whether an action plan based on the results of a safety attitudes questionnaire (SAQ) would influence rates of central line–associated bloodstream infection (CLABSIs) and ventilator-associated pneumonia (VAP) in intensive care units (ICUs) found that the ICUs that used such plans reduced CLABSI rates by 10.2 percent in 2008 compared with 2007, while those without action plans had a 2.2 percent decrease in rates. Similarly, VAP rates decreased by 15.2 percent in units with plans, while VAP rates increased by 4.8 percent in units without them. The study also examined whether the action plans influenced results on the 2008 Safety Attitudes Questionnaire (SAQ) found that units that developed these plans demonstrated higher improvement rates in all domains of the SAQ except working conditions. M. C. Vigorito, L. McNicoll, L. Adams et al., “Improving Safety Culture Results in Rhode Island ICUs: Lessons Learned from the Development of Action-Oriented Plans,” Joint Commission Journal on Quality and Patient Safety, Nov. 2011 37(11):5091AP. 

Low-Quality, High-Cost Hospitals Have Higher Shares of Minority and Poor Patients
A study that sought to assess the potential impact on minority and poor patients of programs designed to improve quality and costs of health care found that the nation’s worst hospitals (those where quality is low and costs high) are typically
small, public or for-profit institutions in the South that care for double the proportion (15% versus 7%) of elderly black patients as the best hospitals, which provide high-quality, low-cost care. Elderly Hispanic and Medicaid patients accounted for 1 percent and 15 percent, respectively, of the patient population at the best hospitals, while at the worst hospitals, these groups represented 4 percent and 23 percent of the patients. Patients with acute myocardial infarction at the worst hospitals had 7 percent to 10 percent higher odds of death compared with patients with those conditions admitted to the best hospitals. The study notes that under Medicare’s forthcoming value-based purchasing program, the worst institutions will have to improve on both costs and quality to avoid incurring financial penalties and exacerbating disparities in care. A. K. Jha, E. J. Orav, and A. M. Epstein, “Low-Quality, High-Cost Hospitals, Mainly in South, Care for Sharply Higher Shares of Elderly Black, Hispanic, and Medicaid Patients,” Health Affairs, October 2011 30(10):1904–11. 

Health Reform’s Risks of Exacerbating Racial and Ethnic Disparities Outlined
The authors of this commentary highlighted the challenges of ensuring that quality improvement efforts tied to the Affordable Care Act reduce racial and ethnic disparities. These include making certain that quality improvement efforts measure disparities and improvements in them; that such efforts not create perverse incentives for providers to avoid serving minority patients; that they be applied to institutions where minority patients are most likely to receive care; and that they fully engage minority patients despite language or other barriers. To assist in these efforts, the authors recommend the development of disparities impact assessments to measure the effect that the Affordable Care Act’s quality provisions will have on reducing disparities. R. M. Weinick and R. Hasnain-Wynia, “Quality Improvement Efforts Under Health Reform: How to Ensure That They Help Reduce Disparities—Not Increase Them,” Health Affairs, October 2011 30(10):1837–43.

Higher Levels of Nurse Staffing Decrease Readmission Odds

A study designed to determine the impact of unit-level nurse staffing on quality of discharge teaching, patient perception of discharge readiness, postdischarge readmission and emergency department (ED) visits, and cost-benefit of adjustments to unit nurse staffing found that higher registered nurse (RN) non-overtime staffing decreased odds of readmission. It also found higher RN overtime staffing increased the odds of ED visits and RN non-overtime staffing reduced ED visits indirectly, via a sequential path through discharge teaching quality and discharge readiness. The study suggests that postdischarge utilization costs could potentially be reduced by investment in nursing care hours to better prepare patients before hospital discharge. M. E. Weiss, O. Yakusheva, and K. L. Bobay, “Quality and Cost Analysis of Nurse Staffing, Discharge Preparation, and Postdischarge Utilization,” Health Services Research, Oct. 2011 46(5):1473–94.

Broader Search for Causes of Readmission Urged
In this commentary, the authors note that while efforts to reduce hospital readmissions have focused on improving the discharge process for medically high-risk patients, this strategy may yield disappointing results because it misses important factors that contribute to readmission, including access to health services and socioeconomic resources such as income and social support. They add that patient-level determinants of readmission also include health status and access to stable housing and food. As a result, the authors recommend using a broader framework to identify alternative strategies to reducing admissions. S. Kangovi and D. Grande, “Hospital Readmissions—Not Just a Measure of QualityJournal of the American Medical Association, October 2011 306(16):1796–97.

Readmission Risk Prediction Models Lacking 

A study that sought to summarize readmission risk prediction models, describe their performance, and assess suitability for clinical or administrative use found current readmission risk prediction models that were designed for either comparative or clinical purposes perform poorly. The authors note that while in certain settings such models may prove useful, efforts to improve their performance are needed as use becomes more widespread. D. Kansagara, H. Englander, A. Salanitro et al., “Risk Prediction Models for Hospital Readmission: A Systematic Review," Journal of the American Medical Association, October 2011 306(15):1688–98. 

Consumers Seeking Quality Information Online Often Find Patient Narratives Rather Than Objective Data
A study that investigated how easy or difficult it is for consumers to locate objective, validated health care information online found that Web sites most likely to be found by consumers are owned by private companies and provide information based on anecdotal patient experiences. Web sites less likely to be found have government or community-based ownership, are based on administrative data, and contain a mixture of quality, cost, and patient experience information. Searches for information on hospitals reveal more cost and quality information based on administrative data, whereas searches that focus on clinics or physicians are more likely to produce information based on patient narratives. B. Sick and J. M. Abraham, “Seek and Ye Shall Find: Consumer Search for Objective Health Care Cost and Quality Information,” American Journal of Medical Quality, Sept. 2011 (e-pub). 

Recommendations to Reduce Unnecessary Hospitalizations from Nursing Homes
The authors of this commentary suggest that multifaceted strategies are needed to reduce unnecessary hospitalizations of nursing home patients. These should include programs to address current incentives for hospitalization. The authors note that interventions designed to reduce preventable hospitalizations should be directed at facilities that have the infrastructure, leadership commitment, and culture of quality and safety necessary to undertake more acute care. J. G. Ouslander and R. A. Berenson, “Reducing Unnecessary Hospitalizations of Nursing Home Residents,” New England Journal of Medicine, September 2011 365(13):1165–67. 

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