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Publications of Note

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.

Health IT Fails to Decrease Hospital Costs
By linking survey data from approximately 4,000 hospitals with administrative cost data from Medicare and cost and quality data from the Dartmouth Atlas of Health Care, researchers found that use of health information technology does not reduce administrative or overall costs at hospitals. Still, it is associated with modest but consistent improvement in process-of-care measures of quality, according to the analysis. Even the hospitals on the cutting edge of computerization (e.g., those identified on Hospitals and Health Networks' "100 Most Wired" list) demonstrated neither cost nor efficiency advantages from health IT investment. The authors suggest several possible explanations, including the expense of the investment, a lag in efficiency gains, and the use of products that favor coding and documentation functions over efficiency. D. U. Himmelstein, A. Wright, and S. Woolhandler, Hospital Computing and the Costs and Quality of Care: A National Study, American Journal of Medicine, January 2010 123(1):40–6.

Medicare Patient Safety Monitoring System Identifies Adverse Drug Events
Using the Medicare Patient Safety Monitoring System, researchers reviewed 25,145 hospital discharge records from 2004 to identify adverse drug events (ADEs) related to exposure to six high-risk medications (warfarin, heparin, LMWH/Factor Xa inhibitor, insulin/hypoglycemic agents, digoxin, and systemic antibiotics). They found these agents present significant risks for ADEs. Using these records, they estimated ADEs occurred in the following percentages of patients: 8.8 percent of patients receiving warfarin; 14.6 percent of those receiving heparin; 9.6 percent of patients receiving LMWH/Factor Xa inhibitor; 10.7 percent of those taking insulin/hypoglycemic agents; and 0.5 percent of patients taking digoxin. The study estimated that 0.6 percent of patients exposed to antibiotics developed an antibiotic-associated Clostridium difficile infection. While the type, frequency, and severity of adverse events varied according to the class of medication, the percentage of patients who died, experienced cardiac arrest, or required emergency life-sustaining measures was highest with ADEs associated with heparin. Overall, patients with ADEs had longer lengths of stay and higher rates of in-hospital mortality than patients without ADEs. D. C. Classen, L. Jaser, and D. S. Budnitz, Adverse Drug Events Among Hospitalized Medicare Patients: Epidemiology and National Estimates from a New Approach to Surveillance, Joint Commission Journal on Quality and Patient Safety, January 2010 36(1):12–21 and AP 1–9.

Quality Improvement Education Lacking, New Nurses Report
A nationwide survey of 436 nurses who graduated between August 2004 and July 2005 found nearly 40 percent of them thought that they were poorly or very poorly prepared for—or had never heard of—quality improvement. Nearly 35 percent thought they were not at all prepared to use error-reporting systems. When asked about specific quality improvement techniques, such as root cause analysis, almost 50 percent thought they were not at all prepared. Similarly, 41.7 percent thought they were not at all prepared to use national patient safety resources. The authors of the study suggest nursing educators and nursing program accreditors, among others, should make such education in quality improvement techniques and goals their highest priority. C. T. Kovner, C. S. Brewer, S. Yingrengreung et al., New Nurses' Views of Quality Improvement Education, Joint Commission Journal on Quality and Patient Safety, January 2010 36(1):29–35 and AP1–5.

Physician Practice Caseloads a Barrier to Performance Measurement
Few primary care physicians see a sufficient number of fee-for-service Medicare patients to produce statistically sound performance measurements. Researchers tested whether they could combine performance results of individual physicians to achieve reliable practice-level performance measures. They found a caseload of 2,526 patients would be required to reliably detect a 10 percent relative difference in ambulatory costs, while the caseload required to detect a 10 percent relative difference in quality measures ranged from 328 (for mammography) to 19,069 patients (for preventable hospitalizations). Using these figures, the researchers determined that 65 percent of all primary care physicians active in the Medicare program work in practices that treat an insufficient number of beneficiaries to differentiate their practices' performance from national quality and cost benchmarks. D. J. Nyweide, W. B. Weeks, D. J. Gottlieb et al., Relationship of Primary Care Physicians' Patient Caseload with Measurement of Quality and Cost Performance, Journal of the American Medical Association, December 2009 302(22):2444–50.

Alternative Measures of Physician Performance
In response to the finding that the majority of primary care practices lack a sufficient caseload of Medicare patients to detect 10 percent differences in cost and quality of care for specific conditions, the author of this editorial proposes broadening the measures by which physician practices are distinguished. He recommends creating quantifiable measures of the underlying attributes of practice organization such as reliability, safety, continuity, and efficiency. Another possibility for primary care practice performance measurement would be to aggregate data from all payers, not just Medicare. Other options would be to solicit information from patients on how well they were treated or to measure and track individual patient's health and function over time. D. M. Berwick, Measuring Physicians' Quality and Performance: Adrift on Lake Wobegon, Journal of the American Medical Association, December 2009 302(22):2485–86.

Ensuring Delivery System Reform Through Accountable Care Organizations and Medical Homes
The authors of this commentary say that establishment of patient-centered medical homes (PCMHs) and accountable care organizations (ACOs) could improve the quality and coordination of health care services and slow spending. Still, they say that safeguards are needed to ensure these models are sustainable and mutually reinforcing. They recommend the development of common standards for primary care performance measurement and the weighting of primary care measures to ensure that shared savings and other financial incentives do not favor hospital and specialty care at the expense of primary care. Accreditation and certification processes for ACOs and PCMHs also should be aligned to support a strong primary care foundation for the health care system. D. R. Rittenhouse, S. M. Shortell, E. S. Fisher et al., Primary Care and Accountable Care — Two Essential Elements of Delivery-System Reform, New England Journal of Medicine, December 2009 361(2):2301–3.

Patient Handoffs Problematic for Resident Physicians
To test the ability of resident physicians to communicate effectively during handoffs, researchers recorded the handoffs of the patients from the emergency department to the inpatient service at a children's hospital and then asked the residents involved to independently rate each patient's severity of illness and list his or her problems. The researchers found in 75 percent of the handoffs, the residents agreed about the severity of the patient's illness. However, there was low agreement about the most severe problem and the total problem list. Attending physicians who listened to recordings of the handoffs were able to identify more patient problems than had been identified by the residents. The researchers concluded that resident physicians may need more formal education and training, as well as evaluation, of their handoffs procedures to improve patient safety. M. L. Brannen, K. A. Cameron, M. Adler et al., Admission Handoff Communications: Clinician's Shared Understanding of Patient Severity of Illness and Problems, Journal of Patient Safety, December 2009 5(4):237–42.

Concern over Postdischarge Adverse Events in Children
The authors of this commentary highlight the need for data on adverse events following the discharge of children from hospitals. The rate at which such events occur in the adult population has become a major public health concern, but no similar data exist on the prevalence of adverse events among recently discharged pediatric patients. The authors recommend that future patient safety research include this topic and identify risk factors for such events. D. Tsilimingras, M. R. Miller, and R .G. Brooks, Postdischarge Adverse Events in Children: A Cause for Concern, Joint Commission Journal on Quality and Patient Safety, December 2009 35(12):620–21.

Report Cards in Canada Less Effective than Expected at Altering Performance
A study of 86 hospital corporations in Ontario, Canada, found the public release of hospital-specific quality data did not significantly improve mean hospital performance on composite process-of-care indicators for acute myocardial infarction or congestive heart failure. The authors suggest that public reporting methods may not be an effective intervention for improving care processes for those conditions across hospitals. Frequent and timely feedback to hospitals may have more impact than the report cards, as might the use of multidisciplinary teams at each hospital to implement a consistent, systemwide approach to improvement based upon report card results. J. V. Tu, L. R. Donovan, D. S. Lee et al., Effectiveness of Public Report Cards for Improving the Quality of Cardiac Care: The EFFECT Study: A Randomized Trial, Journal of the American Medical Association, December 2009, 302(21):2330–37.

Links Between Incentives and Better Patient Experiences
To determine the effect of performance-based financial incentives on improving patient care experiences, researchers used data from the Clinician & Group Survey from the Consumer Assessment of Healthcare Providers and Systems to examine care at 26 California medical groups between 2003 and 2006. They found that physicians improved on measures of communication with patients, care coordination, and office staff interaction; those with lower baseline performance on patient experience measures made greater improvement. Increased emphasis on clinical quality and patient experience criteria in incentive formulas was associated with improvement in measures of care coordination and office staff interaction. In contrast, greater emphasis on productivity and efficiency criteria was associated with declines in performance on the physician communication and office staff interaction composites. H. P. Rodriguez, T. Glahn, M. N. Elliott et al., The Effect of Performance-Based Financial Incentives on Improving Patient Care Experiences: A Statewide Evaluation, Journal of General Internal Medicine, December 2009 24(12):1281–88.

Progress on Patient Safety
In this editorial, the director of the Agency for Healthcare Research and Quality outlines the progress that that agency and others have made in raising awareness of patient safety and creating tools that health care providers can use to identify and systematically address medical errors. The work to date includes efforts to identify the causes of preventable errors; to design, test, and evaluate evidence-based tools and solutions to reduce errors; and to disseminate those solutions widely. C. Clancy, Where We Are a Decade After To Err Is Human, Journal of Patient Safety, December 2009 5(4):199–200.

Little Difference in Mortality Rates for STEMI Patients at High- and Low-Volume Hospitals
A study of the relationship between primary angioplasty volume and outcomes for patients presenting with ST-segment elevation myocardial infarction (STEMI) found little difference in in-hospital mortality rates among high-, medium-, and low-volume hospitals. Earlier studies have suggested an inverse relationship between volume and mortality for this group of patients. The study of 29,513 patients treated between 2001 and 2007 at 166 hospitals across the U.S. did find median door-to-balloon times were higher at low- and medium-volume centers compared with high-volume ones (90 and 88 minutes, versus 90 minutes, respectively). High-volume centers also were more likely than low-volume centers to follow evidence-based guidelines at discharge. The authors suggest the results may be attributable to improvements in angioplasty techniques and standardization of practices nationwide. D. J. Kumbhani, C. P. Cannon, G. C. Fonarow et al., Association of Hospital Primary Angioplasty Volume in ST-Segment Elevation Myocardial Infarction with Quality and Outcomes, Journal of the American Medical Association, November 2009 302(20):2207–13.

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