Selected articles on quality improvement from a number of journals, including the American Journal of Medicine, Annals of Internal Medicine, Archives of Pediatric and Adolescent Medicine, BMJ, Health Affairs, Health Services Research, International Journal for Quality in Health Care, Joint Commission Journal on Quality and Safety, Journal of the American Medical Association, Journal of General Internal Medicine, Journal of Patient Safety, Journal of Safety and Quality in Health Care, Medical Care, The Milbank Quarterly, The New England Journal of Medicine, and Pediatrics. The articles are nominated by Editorial Advisory Board members from a preselected list.
Putting a Price on Quality Improvement
In an attempt to quantify the cost of inpatient quality improvement activities, researchers surveyed four urban, nonprofit, acute care teaching hospitals from a high-performing health care system. The researchers found the hospitals spent between $200 to $400 per discharge, or 1 to 2 percent of total operating revenue, on activities that fell into categories of patient safety, quality measurement and reporting, staff incentives and education, patient satisfaction, information systems, and leadership efforts on quality improvement. The hospitals demonstrated great variability in how they allocated funds for those activities. Resources dedicated to patient safety projects ranged from $10 to $80 per discharge, while those for computerized physician order entry ranged from $20 to $140 per discharge. L. M. Chen, M. S. Rein, and D. W. Bates, Costs of Quality Improvement: A Survey of Four Acute Care Hospitals, Joint Commission Journal on Quality and Patient Safety, November 2009 35(11):544–50.
Emerging Digital Divide Among Hospitals
A national survey of acute care hospitals found those caring for a higher proportion of Medicaid patients, elderly black patients, elderly Hispanic patients, and a substantially lower proportion of Medicare patients were less likely to use electronic medication lists and electronic discharge summaries, as well as clinical decision-support tools, compared with hospitals that care that for the lowest proportion of such patients. The researchers found that these hospitals lagged in quality performance as well, although the survey findings suggested that association could be mitigated by the use of electronic medical records. The researchers note that federal guidance and technical assistance may be necessary to ensure that states participate in recent Medicaid incentive programs designed to spur adoption of health information technology in safety net hospitals. A. K. Jha, C. M. DesRoches, A. E. Shields et al., Evidence of an Emerging Digital Divide Among Hospitals That Care for the Poor, Health Affairs Web Exclusive, Oct. 26, 2009.
Targeting Care Management at Costliest Patients
The authors of this perspective propose expanding care management programs as a means of reducing costs and enhancing quality for patients with multiple chronic conditions, who account for the vast majority of Medicare expenditures and could benefit from support in managing their medical conditions. Because care management services are intensive and expensive, the authors argue they should be targeted to patients with complex problems who are at high risk of requiring costly care. Payment incentives may also help to encourage physicians and hospitals to participate in care management programs. T. Bodenheimer and R. Berry-Millett, Follow the Money—Controlling Expenditures by Improving Care for Patients Needing Costly Services, New England Journal of Medicine, October 2009 361(16):1521–23.
Variation in Hospital Mortality Associated with Inpatient Surgery
Using data from a multi-center clinical registry of patients who had undergone one of 42 inpatient general and vascular operations between 2005 and 2007, researchers found that hospitals with low and high mortality rates had no clinically important differences in rates of post-operative complications. But researchers found that patients at hospitals with very high mortality rates (i.e., hospitals in a quintile with an average risk-adjusted mortality rate of 6.9 percent) had nearly two times the likelihood of dying after the development of a major complication, compared with patients at low-mortality hospitals (i.e., hospitals in a quintile with an average risk-adjusted mortality rate of 3.5 percent)—21.4 percent versus 12.5 percent, respectively. The study, which included 84,730 patients, emphasizes the importance of recognizing and managing post-surgical complications once they occur. A. A. Ghaferi, J. D. Birkmeyer, and J. B. Dimick, Variation in Hospital Mortality Associated with Inpatient Surgery, New England Journal of Medicine, October 2009 361(14):1368–75.
Comparing Safety Climate Between VA and Other U.S. Hospitals
In this study, researchers compared the hospital safety climate in 29 Veterans Health Administration (V.A.) hospitals with that of 67 independent, public and private acute care hospitals, using a cross-sectional survey of hospital employees, including senior managers, physicians, and frontline employees. While employees' perceptions of the safety climate in the V.A. and non-V.A. hospitals were similar, there were significant differences with respect to specific dimensions, including the level of senior management's engagement and organizational resources devoted to safety—with employees of non-V.A. hospitals expressing more confidence in hospital safety than employees in V.A. hospitals. The researchers suggested that the advantages associated with the V.A. system's intense focus on safety improvement may be less important in promoting a patient safety culture than other factors such as "hospitals' emphasis on creativity and innovation and their leaders' abilities to motivate, implement and sustain improvement." S. J. Singer, C. W. Hartmann, A. Hanchate et al., Comparing Safety Climate Between Two Populations of Hospitals in the United States, Health Services Research, October 2009 44(5):1563–84.
Calculating the Effect of P4P Programs
In an effort to determine how the design and selection of pay-for-performance (P4P) strategies affect providers' incentives to improve quality, researchers used publicly available data on hospital performance to calculate hospital bonuses under five common P4P models. The bonus payments were based on the number of patients who received recommended care for acute myocardial infarction, heart failure, and pneumonia. Using the results of the simulation, researchers outlined the advantages and disadvantages of each payment strategy. As an example, the researchers found rank-order systems are useful to create payment gradients when the bonus pool is limited, and that target-attainment models combined with improvement and percentage-payment strategies come closest to rewarding both performance level and improvement. R. M. Werner and R. A. Dudley, Making the 'Pay' Matter in Pay-for-Performance: Implications for Payment Strategies, Health Affairs, September/October 2009 28(5):1498–1508.
Costs, Quality of Care at Retail Clinics
A study of claims data from a large Minnesota health plan demonstrated that overall costs of care of three conditions (otitis media, pharyngitis, and urinary tract infections) were 30 to 40 percent lower at retail clinics than in physician offices and urgent care centers, and 80 percent lower than in emergency departments. The study also found the quality of care provided at the retail clinics was similar to that provided in physician offices and urgent centers and was slightly superior to that in emergency departments. Further, the researchers found that visits to retail clinics did not disrupt opportunities to receive preventive care at physician offices, as some critics of retail clinics contend. A. Mehrotra, H. Liu, J. L. Adams et al., Comparing Costs and Quality of Care at Retail Clinics with That of Other Medical Settings for 3 Common Illnesses, Annals of Internal Medicine, September 2009 151(5):321–28.
Effect of Order Entry and Decision Support on Pediatric Medication Errors
By analyzing the rates of prescription errors in a 12-bed pediatric intensive care unit before and after computerized physician order entry (CPOE) was implemented and before and after a clinical decision support system (CDSS) was added to limit medication doses by weight, researchers were able to determine that CPOE implementation alone had only a minimal impact on reducing prescription errors. But when CPOE was combined with CDSS to limit doses by weight, the number of prescription errors dropped dramatically. Using both tools, overall prescription errors were reduced by 83 percent and adverse drug events were reduced by 72 percent. G. Kadmon, E. Bron-Harlev, E. Nahum et al., Computerized Order Entry with Limited Decision Support to Prevent Prescription Errors in a PICU, Pediatrics, September 2009 124(3): 935–40.
Limits to Diabetes Care Management Using EHRs
A study of the methods and processes for coordinating diabetes care in four Kaiser Permanente medical centers, which used four different care models, found all relied heavily on electronic health record (EHR) systems. While the EHRs provided sufficient information to prevent gaps and overlaps in care, it did not address certain care coordination challenges, including communication problems that arose when providers differed about treatment priorities and actions. Instead of addressing such differences, many providers simply reversed the preceding caregiver's treatment priorities or plans. The researchers also noted that challenges arose when patients' needs went beyond the discipline-specific focus of the caregiver and when physicians, midlevel providers, and nurses had conflicting expectations of one another's roles. L. H. MacPhail, E. B. Neuwirth, and J. Bellows, Coordination of Diabetes Care in Four Delivery Models Using an Electronic Health Record, Medical Care, September 2009 47(9):993–99.
Fatigue, Distress, and Perceived Medical Errors Among Residents
Researchers studying the association between fatigue and distress with self-perceived major medical errors among resident physicians found that higher levels of fatigue and distress are independently associated with self-perceived medical errors. The study showed the risk of internal medicine residents reporting a major medical error could increase 15 percent, 20 percent, and 28 percent, respectively, as fatigue, depression, or both increase. Because resident distress can and does occur independently of fatigue, residency programs must guard against both burnout and depression in residents. C. P. West, A. D. Tan, T. M. Habermann et al., Association of Resident Fatigue and Distress with Perceived Medical Errors, Journal of the American Medical Association, September 2009 302(12):1294–1300.
Data Network to Support Comparative Effectiveness Research
This article provides an overview of the Distributed Ambulatory Research in Therapeutics Network (DARTNet), a federated network that links health data from geographically and organizationally separate databases in eight organizations, representing more than 500 clinicians and 400,000 patients. The network enables researchers to conduct comparative effectiveness research by gathering de-identified patient information from electronic health records, laboratory tests, imaging results, pharmacy utilization databases, and billing systems. DARTNet, which was funded by the Agency for Healthcare Research and Quality, also can be used to prompt physicians to obtain specific information during a patient encounter and is designed to support learning communities by identifying high-performing practices and systems. W. D. Pace, M. Cifuentes, R. J. Valuck et al., An Electronic Practice-Based Network for Observational Comparative Effectiveness Research, Annals of Internal Medicine, September 2009 151(5): 338–40.
A New Charter for Primary Care
After outlining the political, economic, policy, and institutional factors that have led to a decades-long decline in U.S. primary care, the authors of this paper propose a plan to reverse its devaluation. "The New Charter for Primary Care" calls for dramatic changes in medical education, provider reimbursement, practice infrastructure, and performance measurement to balance the supply of primary care providers with secondary/tertiary care providers. Among the recommendations: adjusting reimbursement to recognize the value of individual and population health, care coordination, and comprehensive, personalized longitundinal care and redirecting graduate medical education funds from hospitals to graduate educational training programs, with the requirement that half of these funds be targeted to primary care training. The authors argue that efforts to improve primary care through the introduction of patient-centered medical homes, while important, are insufficient to overcome the fundamental imbalances in payment and resources devoted to primary care in the U.S. L. G. Sandy, T. Bodenheimer, L. G. Pawlson et al., The Political Economy of U.S. Primary Care, Health Affairs, July/August 2009 28(4):1136–45.
New from The Commonwealth Fund
New State Scorecard
Focused on identifying opportunities to improve, The Commonwealth Fund's State Scorecard on Health System Performance assesses states’ performance on health care relative to achievable benchmarks for 38 indicators of access, quality, costs, and health outcomes. The 2009 State Scorecard paints a picture of health care systems under stress, with deteriorating health insurance coverage for adults and rising health care costs. On a positive note, there were gains in children's coverage as a result of national reforms, and improvement in some measures of hospital and nursing home care following federal efforts to publicly report quality data. The scorecard highlights persistent wide variation in performance across states and continued evidence of poor care coordination. Increasing cost pressures and deterioration in access across the U.S., together with geographic disparities in performance, underscore the urgent need for comprehensive national reforms to ensure access, change the trajectory of costs, and enhance value. D. McCarthy, S. K. H. How, C. Schoen, J. C. Cantor, D. Belloff, Aiming Higher Results from a State Scorecard on Health System Performance, 2009, The Commonwealth Fund, October 2009.
International Survey: U.S. Lags in Access, Quality, Use of Health IT
A study of more than 10,000 primary care physicians in 11 countries finds the United States lags far behind in terms of access to care, the use of financial incentives to improve the quality of care, and the use of health information technology. In other countries, national policies have sped the adoption of such innovations. C. Schoen, R. Osborn, M. M. Doty, D. Squires, J. Peugh, and S. Applebaum, A Survey of Primary Care Physicians in 11 Countries, 2009: Perspectives on Care, Costs, and Experiences, Health Affairs Web Exclusive, Nov. 5, 2009, w1171–w1183.