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Publications of Note

Process Improvement Linked to Improved Outcomes
A study designed to determine whether hospital performance improved after the Hospital Quality Alliance began publicly reporting process indicators through the Web site Hospital Compare found that improvements were associated with better patient outcomes. For acute myocardial infarction, improvements were associated with declines in mortality rates, lengths of stay, and readmission rates. More specifically, a 10-point increase in performance was associated with declines in mortality rates of 0.6 percentage points; lengths of stay, 0.19 days; and readmission rates, 0.5 percentage points. Changes in outcomes for heart failure and pneumonia were less consistent and smaller, when present. R. M. Werner and E. T. Bradlow, Public Reporting on Hospital Process Improvements Is Linked to Better Patient Outcomes, Health Affairs, July 2010 29(7):1319–24.

Guidelines for Stimulating Accountable Care Organizations Suggested
In this commentary, the authors suggest that the Center for Medicare and Medicaid Innovation, a newly created office within the Centers for Medicare and Medicaid Services, encourage the development of accountable care organizations (ACOs) by communicating their benefits to providers and creating a system for learning from previous experiments with ACOs. To address the different states of readiness to form ACOs among physician organizations, the authors also recommend that the center create a tiered system of payment models so that physicians can choose one that best fits their needs and circumstances. In the first tier, the ACO might bear little financial risk but would be eligible to receive shared savings and bonuses if it meets quality benchmarks and reduces per-beneficiary spending below a certain target. In the second tier, the ACO might be paid through partial capitation and selected bundled payments. It might be eligible to receive a greater proportion of savings if it achieves spending targets below a specified target, but the ACO would also be at risk for spending above the target. Groups in the second tier would be required to report more comprehensive data on performance measures. Finally, in the third tier, ACOs would be reimbursed through full capitation or extensive partial capitation and bundled payments. Qualifying criteria for the third tier might include public reporting of comprehensive data on performance measures; these ACOs might also be required to meet more stringent requirements for financial reporting and cash reserves. S. M. Shortell, L .P. Casalino, and E. S. Fisher, How the Center for Medicare and Medicaid Innovation Should Test Accountable Care Organizations, Health Affairs, July 2010 29(7):1293–8.

Patient–Physician E-Mail Appears to Improve Quality of Care
A study of 35,423 patients with hypertension, diabetes, or both found the use of secure patient to physician e-mail was associated with more effective care, as measured by the Healthcare Effectiveness Data and Information Set (HEDIS). The study of patients of Kaiser Permanente, an integrated delivery system, found the proportion of patients whose HEDIS measures improved ranged from 4 percent to 11. 1 percent. Secure patient–physician e-mail was associated with an improvement in performance on blood glucose screening and control, cholesterol screening and control, retinopathy screening, and nephropathy screening of 2.4 to 6.5 percent. It was also associated with improved performance on blood pressure control among patients with diabetes and with blood pressure control among patients with hypertension alone. The authors suggest a randomized controlled study is necessary to confirm the association. Y. Y. Zhou, M. H. Kanter, J. J. Wang et al., Improved Quality at Kaiser Permanente Through E-Mail Between Physicians and Patients,Health Affairs, July 2010 29(7):1370–5.

Changes to Meaningful Use Regulation Explained
In a commentary, the national coordinator for health information technology at the Department of Health and Human Services and the principal deputy administrator of the Centers for Medicare and Medicaid Services outlined the criteria hospitals and physicians must meet to qualify for incentive payments under the Health Information Technology for Economic and Clinical Health Act (HITECH). The authors explained how the regulation had been revised to address concerns that few providers could meet the qualifications for incentive payments. The revised regulation reduces the number of obligations physicians and hospitals must meet by requiring them to fulfill a set of 15 core obligations and select from a menu of other important activities to meet five other obligations. "The meaningful use rule strikes a balance between acknowledging the urgency of adopting EHRs (electronic health records) to improve our health system and recognizing the challenges that adoption will pose to health care providers. The regulation must be both ambitious and achievable," the authors said. D. Blumenthal and M. Tavenner, The Meaningful Use Regulation for Electronic Medical Records, New England Journal of Medicine, published online July 13, 2010.

Prescribing Errors in Ambulatory Settings Reduced by E-Prescribing System
To assess the impact of a standalone e-prescribing system on the rates and types of prescribing errors in community-based office practices, researchers analyzed the records of 15 providers who adopted an e-prescribing system and compared them with those of 15 providers using paper-based systems. The physicians were located in the rural and suburban Hudson Valley region of New York. The researchers found that error rates among e-prescribers decreased from 42.5 per 100 prescriptions to 6.6 per 100 one year after adoption. For non-adopters, the error rates remained high, at 37.3 per 100 at baseline and 38.4 per 100 at one year. The authors concluded that prescribing errors may occur much more frequently in community-based practices than previously reported. R. Kaushal, L. M. Kern, Y. Barrón et al., Electronic Prescribing Improves Medication Safety in Community-Based Office Practices, Journal of General Internal Medicine, June 2010 25(6):530–6.

Group Visits Effective for Treating Hypertension But Not Diabetes
A randomized trial designed to evaluate the effectiveness of using group visits to treat uncontrolled blood glucose and blood pressure in patients with both diabetes and hypertension found patients who attended the group visits at two Veterans Affairs Medical Centers had better blood pressure control at six months than those in the usual care group and the results were sustained at one year. Group visits did not improve blood glucose control in the same patients, compared with the usual care group. The group visits included seven to eight patients and a care team that consisted of a primary care general internist, a pharmacist, and a nurse or other certified diabetes educator. Each session included structured group interactions moderated by the educator. The pharmacist and physician adjusted medication to manage each patient's blood glucose level and blood pressure. The annual cost of the program, which was $460 per patient, might be offset by reductions in emergency department and primary care visits, the researchers noted. D. Edelman, S. K. Fredrickson, S .D. Melnyk et al., Medical Clinics Versus Usual Care for Patients with Both Diabetes and Hypertension: A Randomized Trial, Annals of Internal Medicine, June 2010 152(11): 689–96.

Patients' Care Experiences Worse in High-Intensity Markets
More intensive use of Medicare services by fee-for-service and managed care beneficiaries is associated with worse or no better care experiences, according to a study that linked resource use intensity in 306 markets with data from the 2003 Consumer Assessment of Healthcare Providers and Systems surveys. For all beneficiaries across the 306 markets, problems with access to care and getting care when needed were more frequent in high-intensity areas than in low-intensity areas. Despite this, beneficiaries in high-intensity areas rated their personal physicians more highly than their counterparts in low-intensity markets. J. N. Mittler, B. E. Landon, E. S. Fisher et al., Market Variations in Intensity of Medicare Service Use and Beneficiary Experiences with Care, Health Services Research, June 2010 45(3): 647–9.

Publicly Reported SCIP Measures Not Linked to Lower Infection Rates
A study that examined whether adherence to Surgical Care Improvement Project (SCIP) measures was associated with postoperative infection rates found adherence on individual SCIP measures—the only measures for which performance is publicly reported—was not associated with a significantly lower probability of infection. However, adherence measured through an "all-or-none" composite infection-prevention score was associated with a lower probability of developing a postoperative infection. This suggests improved methods for identifying quality-of-care are necessary. Further, the lack of an association between individual process-of-care measures and clinical outcomes suggests reimbursement schemes based on these items would be ineffective. The researchers used Premier Inc.'s Perspective Database to study discharges between July 1, 2006 and March 31, 2008, in 398 hospitals. J. J. Stulberg, C. P. Delaney, D. V. Neuhauser et al.,
Adherence to Surgical Care Improvement Project Measures and the Association with Postoperative Infections, Journal of the American Medical Association, June 2010 303(24):2479–85.

Drawbacks in Hospital Outcomes Measures Outlined
In this commentary, the author points out how current methods of assessing hospital performance lead to an incomplete picture of hospital outcomes and resource use and distract from population-based approaches needed to assess community performance. The Dartmouth Atlas hospital-specific end-of-life measures calculate expenditures for decedents and exclude data on the care of survivors. Alternate methods that follow index admissions and measure outcomes for patient who lived or died miss patients treated outside the hospital. By contrast, community-level or population-based measures require consideration of all patients with a specific disease—those who lived or died and those who received treatment in a hospital or did not. The author suggests investment in health information technology and the use of all-payer databases may help capture this missing information. M. D. Huesch, Payment Policy Based on Measurement of Health Care Spending and Outcomes, Journal of the American Medical Association, June 2010 303(23):2405–6.

Rules for Determining Responsible Physician Change Physician Cost Profiles
Before developing cost profiles of physicians, health plans must first determine which physician is responsible for the care a patient received. There are many rules for attributing care to physicians. To determine whether these attribution rules change the classification of physicians as high-, average-, or low-cost providers, researchers applied 12 different attribution rules to aggregated claims submitted to four different commercial health plans in Massachusetts. They found that compared with the most commonly used rule, 17 percent to 61 percent of physicians would be assigned to a different category under an alternate attribution rules. In practical terms, this means that two health plans in the same region would frequently assign a physician to different cost categories even though the physician's care pattern did not change. Because different attribution rules relay information important to physicians, patients, and payers, among others, the researchers suggest health plans create cost profiles that are transparent in their methodology. This will enable users to determine whether the score is relevant for their purposes. A. Mehrotra, J. L. Adams, J. W. Thomas et al., The Effect of Different Attribution Rules on Individual Physician Cost Profiles, Annals of Internal Medicine, May 2010 152(10): 649–54.

Physician–Nurse Communication Poor, Study Finds
A study of communication between physicians and nurses caring for hospitalized patients during a one-month period revealed significant communication problems. Nurses correctly identified patients' physicians 71 percent of the time and reported communicating with them 50 percent of the time. Physicians correctly identified the patients' nurses 36 percent of the time and reported communicating with them 62 percent of the time. Physicians and nurses showed no agreement on aspects of the plan of care ranging from 11 percent for planned procedures to 42 percent for medication changes. K. J. O'Leary, J. A. Thompson, M. P. Landler et al., Patterns of Nurse–Physician Communication and Agreement on the Plan of Care, Quality and Safety in Health Care, April 2010 19(3):195–9.

Health Plan-Level Data Useful for Distinguishing Quality of Care
A study designed to determine the separate impact of health plans and physician groups on quality measures found variation across provider organizations explains much of the variation in Healthcare Effectiveness Data and Information Set (HEDIS) scores. However, the researchers, who relied on data from six health plans and 159 provider organizations in California, found significant differences across health plans in HEDIS rates that were not significantly changed when they controlled for the provider organization caring for the patient. The results suggest that health plans can influence quality independent of physician groups and that the collection of plan-level data is warranted. L. C. Baker and D. S. P. Hopkins, The Contribution of Health Plans and Provider Organizations to Variations in Measured Plan Quality, International Journal for Quality in Health Care, March 2010 22(3):210–8.

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