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Publications of Note

EHR Initially Impairs Performance on Quality Measures, Health Center Finds
In a letter to the editor, two physicians from a community health center in South Dakota noted that electronic health record (EHR) implementation was associated with a decrease in quality improvement performance in the first year. Performance on measures of diabetes control and hypertension control declined among the clinic's providers, as did rates of pediatric immunizations and Pap smears. These declines occurred despite the fact that a quality improvement implementation and tracking system had been in place and was widely accepted by clinical and administrative staff. The authors suggested the decline might have been the result of user or system inefficiencies, increasing insensitivity to electronic reminders, and/or distraction of personnel during the implementation phase. M. Huntington and C. W. Shafer, EHR Implementation Adversely Affects Performance on Process Quality Measures in a Community Health Center, American Journal of Medical Quality, September/October 2010 25(5):404–5.

Financial Incentives Didn't Harm Hospitals Caring for the Poor
Studying how financial incentives affected quality performance at hospitals with high and low levels of poor patients, researchers found no evidence indicating that financial incentives widened the gap in performance between hospitals that serve poor patients and other hospitals, as some critics of pay-for-performance programs have feared. The study compared changes in performance on quality measures for care of acute myocardial infarction, congestive heart failure, and pneumonia at hospitals that participated in the Premier Hospital Quality Incentive Demonstration program and those that did not. Hospitals that participated in the program and serve a greater number of poor patients had lower baseline performance than other hospitals, but demonstrated greater improvements in performance for acute myocardial infarction and pneumonia, but not congestive heart failure. The gains were greater among hospitals that received financial incentives than among a national sample. A. K. Jha, E. J. Orav, and A. M. Epstein, The Effect of Financial Incentives on Hospitals That Serve Poor Patients, Annals of Internal Medicine, September 2010 153(5):299–306.

Auto-Assignment Incentive Has Limited Effect on Quality
A study designed to assess the impact of a pay-for-performance program on quality outcomes in California's Medicaid plans found comparable outcomes in plans that benefited from the program and those that did not. The pay-for-performance program automatically assigned new enrollees to better-performing Medicaid plans. The authors found the plans changed the focus of their quality improvement programs to match those that were prioritized by Medicaid, whether or not they received the benefit of the program, but did not invest new resources in quality improvement. Discussions with plan leaders suggested the incentive might not be large or transparent enough to change plan behavior significantly. B. Guthrie, G. Auerback, and A. B. Bindman, Health Plan Competition for Medicaid Enrollees Based on Performance Does Not Improve Quality of CareHealth Affairs, Sept. 2010 29(8):1507–16.

Physician Performance Rankings Reduced by Patient Panel Characteristics
A study linking patient panel characteristics to clinical performance rankings of primary care physicians practicing in a large academic health care system found physicians whose patient panels had greater proportions of underinsured, minority, and non-English-speaking patients had lower quality rankings. The study also found patients of primary care physicians in the top third of quality performance were older, had a higher number of co-morbidities, and made more frequent primary care visits. The primary care physicians in the top third of rankings also had fewer minority patients, patients with Medicaid coverage, or without insurance. The authors adjusted rankings for patient panel factors, which resulted in a relative mean change in physician rankings of 7.6 percentage points; such changes in physician rankings have important consequences for performance incentive programs and quality reporting. These findings may complicate efforts by health systems to reward physicians for higher measured quality of care; they must find a way to adjust for patient panel characteristics without removing incentives for improvement, the authors conclude. For the analysis, researchers ranked physicians according to a composite of commonly used Healthcare Effectiveness Data and Information Set (HEDIS) measures. C. S. Hong, S. J. Atlas, Y. Chang et al., Relationship Between Patient Panel Characteristics and Primary Care Physician Clinical Performance Rankings, Journal of the American Medical Association, Sept. 2010 304(10):1107–13.

More Rigorous Approach to Community Health Worker Evaluations Needed, Study Finds
A systematic review of studies published on outcomes and costs of community health worker interventions between 1980 and 2008 found community health workers can improve outcomes for some health conditions such as back pain; however, other results were mixed. Some studies suggested that community health worker interventions could result in greater improvements in participant behavior and health outcomes, while others found no statistically different results than alternative approaches. The reviewers suggest more research is required to address methodological limitations of prior studies. Cost-effectiveness analyses should also be conducted to determine the interventions' impact on urgent care utilization and quality-adjusted life years. M. Viswanathan, J. L. Kraschnewski, B. Nishikawa et al., Outcomes and Costs of Community Health Worker Interventions: A Systematic Review, Medical Care, Sept. 2010 48(9):792–808.

Community Health Centers Make Progress, But Need Funding to Support Improvement
A review of literature on Health Disparities Collaboratives (HDCs), quality improvement collaboratives designed to improve care in 900 community health centers in the U.S., found the HDCs improve clinical processes of care over a short-term period (1–2 years) and clinical processes and outcomes over a longer period (2–4 years) and that most participants perceive the HDCs to be successful and worthwhile. Analysis of the Diabetes Collaborative found it was cost-effective, but that consistent revenue streams were not available to sustain it. Policy reforms are necessary to address this. The author notes priorities for funding include money for direct patient services, data entry, and staff time. Low-cost methods to increase staff morale and prevent burnout include personal recognition, skills development opportunities, and fair distribution of work, the author found. M. Chin, Quality Improvement Implementation and Disparities: The Case of the Health Disparities Collaboratives, Medical Care, Aug. 2010 48(8):668–75.

V.H.A. Finds Providers Explain Some System-Level Variation in Quality and Patient Satisfaction
A study that sought to determine the amounts of variation in technical quality and patient satisfaction attributable to patients, providers, clinical teams, or medical centers at the Veterans Health Administration (VHA) found that providers accounted for the largest percent of variance in the delivery system for all technical quality domains (ranging from 46.5 percent to 71.9 percent). The study also found that medical centers, teams, and providers account for roughly the same level of system-level variance in the measure for patient satisfaction. For the doctor/patient interaction scale, providers explained 59.9 percent of system-level variance, more than twice that of teams and medical centers. K. L. Stolzmann, M. Meterko, M. Shwartz et al., Accounting for Variation in Technical Quality and Patient Satisfaction: The Contribution of Patient, Provider, Team, and Medical Center, Medical Care, Aug. 2010 48(8):676–82.

Quality of Colonoscopies Performed by Primary Care Physicians Comparable to Specialists
A study of primary care physician–performed colonoscopies found that performance quality indicators and lesion detection rates were comparable to documented rates for experienced gastroenterologists. The study, which collected data on 10,958 consecutive colonoscopies performed by 51 physicians who worked with a trained technician and had standby specialist support, suggests that primary care physicians may be used to improve the nation's colonoscopy screening rate. In 2002, primary care physicians provided only 2 percent of colonoscopies nationwide. S. Xirasagar, T. G. Hurley, L. Sros et al., Quality and Safety of Screening Colonoscopies Performed by Primary Care Physicians with Standby Specialist Support, Medical Care, Aug. 2010 48(8):703–9.

Changes in Practice Guidelines Produced Marked Shift in Indicated Procedures for PCIs
A study designed to determine whether changes to clinical practice guidelines affected whether a procedure was indicated found that a guideline change related to percutaneous coronary interventions (PCIs) produced a marked shift in whether PCI that took place in 2003–4 were considered indicated. The percentage for which there was evidence and/or general agreement that the procedure would be effective declined from 47.9 percent when applying 2001 guidelines to 25.1 percent when applying 2005 guidelines. The authors concluded that changes to guideline-based performance measures should be evaluated carefully before implementation to avoid incorrect assessments of quality of care. G. A. Lin, R. F. Redberg, H. V. Anderson et al., Impact of Changes in Clinical Practice Guidelines on Assessment of Quality of Care, Medical Care, Aug. 2010 48(8):733–8.

Health Plan Quality Measures Are a Function of Physician Practice Patterns, Study Finds
A study designed to determine the extent to which health plan quality measures reflect physician practice patterns rather than plan characteristics found that the gaps in scores between plans disappear when they share common physician panels. This suggests that standard heath plan performance measures capture physician practice patterns rather than plans' efforts to improve quality. The authors urge patients to use caution in rating health plans using Healthcare Effectiveness Data Set scores and Consumer Assessment of Healthcare Providers and Systems data, as those scores are likely to reflect provider practice style and behavior in instances where there is a high degree of physician overlap between plans. Because health plans may invest less in quality improvement programs when their providers networks overlap, the authors also suggest that in the presence of increasingly overlapping provider networks, quality improvement initiatives would be more productive if sponsored by the community rather than individual health plans. D. D. Maeng, D. P. Scanlon, M. E. Chernew et al., The Relationship Between Health Plan Performance Measures and Physician Network Overlap: Implications for Measuring Plan Quality, Health Services Research, August 2010 45(4):1005–23.

Treatment of Hepatitis C Virus Suboptimal
A study of 10,385 patients with hepatitis C virus (HCV) infection found fewer than 20 percent received all of the care recommended by the performance guidelines attached to Medicare's 2009 Physician Quality Reporting initiative. Performance was lowest for vaccination (21.5 percent) and highest for pre-treatment HCV genotype testing (79 percent). Older age and presence of co-morbid conditions were associated with lower quality, whereas elevated liver enzyme levels, cirrhosis, and HIV infection were associated with higher quality. The researchers found patients who saw both generalists and specialists were most likely to receive any recommended care process. F. Kanwal, M. S. Schnitzler, B. R. Bacon et al., Quality of Care in Patients with Chronic Hepatitis C Virus Infection, Annals of Internal Medicine, August 2010 153(4):231–9.

Interruptions and Multitasking Implicated in Clinical Inefficiency and Error
A study of emergency department physicians in a teaching hospital found physicians reduced the amount of time they spent on clinical tasks when they were interrupted. The authors suggest the task-shortening may occur as physicians attempt to catch up for lost time. The study also found the physicians delayed or failed to return to a significant portion of interrupted tasks. In all, the doctors failed to return to 18.5 percent of interrupted tasks. J. I. Westbrook E. Coiera, W. T. M. Dunsuir et al., The Impact of Interruptions on Clinical Task Completion, Quality and Safety in Health Care, Aug. 2010 19(4)284–9.

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