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Publications of Note

Performance on Quality Measures Remains Strong After Oversight Stops
Researchers who hypothesized that performance would drop when quality of care measures were no longer actively monitored found no significant difference in performance after those measures were retired. The authors of the study, which relied on data from 133 Veterans Health Administration Medical Centers, concluded that other features of the health care system, such as organizational policies and procedures, may help sustain performance. The study reviewed clinical performance on 17 measures covering five clinical areas common to ambulatory care: screening, immunization, chronic care after acute myocardial infarction, diabetes mellitus, and hypertension. S. J. Hysong, M. M. Kahn, and L. A. Peterson, "Passive Monitoring Versus Active Assessment of Clinical Performance: Impact on Measured Quality of Care," Medical Care, Oct. 2011 49(10):883–90.

VAP Prevention Rates Higher with Monitoring and Compliance Policies
A study examined rates of adoption of the " ventilator bundle," a protocol to reduce ventilator-associated pneumonia (VAP), and assessed the effectiveness of individual elements of the bundle at reducing VAP. Researchers found that 284 of 415 intensive care units reported the presence of a full ventilator policy, but only 66 percent monitored its implementation. Of those, 39 percent reported high compliance. However, only when an intensive care unit had a policy, monitored compliance, and achieved high compliance were VAP rates lower. Compliance with individual elements or just one of two infection-related elements had no impact on rates of VAP. M. Pogorzelska, P. W. Stone, E. Y. Furuya et al., "Impact of the Ventilator Bundle on Ventilator-Associated Pneumonia in Intensive Care Unit," International Journal of Quality in Health Care, Oct. 2011 23(5):538–44.

CLABSI Reporting Methods Vary by State
A survey of state health department Web sites found wide variation in publicly available data about central line–associated bloodstream infections (CLABSIs). In a review of information available from 14 states, all with mandatory CLABSI monitoring laws, the authors found significant variation in the presentation of infection rates, methods of risk adjustment, locations and care settings reported, time span of data collection, and time lag to reporting. The wide variation in availability and content of information illustrates the need for standardized CLABSI monitoring and reporting mechanisms, the authors concluded. M. S. Aswani, J. Reagan, L. Jin et al., "Variation in Public Reporting of Central Line–Associated Bloodstream Infections by State," American Journal of Medical Quality, Sept./Oct. 2011 26(5):387–95.

Cost of CLABSI Prevention Efforts Substantially Lower Than Infection Costs
A study designed to assess the costs and benefits of a collaborative that provided hospitals with the tools and training to reduce catheter-related bloodstream infections found the program averted 29.9 such infections and 18.0 cases of ventilator-associated pneumonia per hospital on an annual basis. The cost of the intervention used in the Michigan Keystone ICU Patient Safety Program was $3,375 per infection, as measured in 2007 dollars, substantially less than estimates of the additional health care costs associated with these infections, which range from $12,208 to $56,167 per episode. The results do not take into account the additional effect of the program's efforts to reduce cases of sepsis or its effects in terms of preventing mortality, improving teamwork, and reducing nurse turnover. H. R. Waters, R. Korn, E. Colantuoni et al., "The Business Case for Quality: Economic Analysis of the Michigan Keystone Patient Safety Program in ICUs," American Journal of Medical Quality, Sept./Oct. 2011 26(5):333–9. 

Pay-for-Performance Program Boosts Cardiovascular Quality
A study designed to assess the impact of a pay-for-performance (P4P) program on the quality of care and outcomes among cardiovascular disease patients found that patients who were treated by physicians participating in the P4P program were more likely to receive quality care as measured by lipid monitoring and treatment, compared with patients whose physicians were not participating in the program. The study also found patients who received quality care were less likely to have new coronary events, be hospitalized, or have uncontrolled lipids than patients who did not. J. Y. Chen, H. Tian, D. T. Juarez et al., "Does Pay for Performance Improve Cardiovascular Care in a 'Real-World' Setting?" American Journal of Medical Quality, Sept./Oct. 2011 26(5):340–8.

Telehealth-Based Care Management Program Yields Savings
A study of the Healthy Buddy Program, a Medicare demonstration that used care management techniques and a telehealth tool to improve care of patients with heart failure, chronic obstructive pulmonary disease, and diabetes, found the program was associated with spending reductions of approximately 7.7 percent to 13.3 percent ($312–$542) per person per quarter. Patients who enrolled in the program received the Health Buddy device, a handheld tool that prompts users to answer daily questions about their symptoms, vital signs, knowledge, and health behavior. The responses were uploaded to a Web-based computer application that risk-stratified responses for review by a care manager. The results did not factor in the cost of the program; had those been included, the program would have resulted in a net savings of roughly 4.3 percent to 9.8 percent. The authors also found mortality differences in the treatment and control groups that suggest intervention may have produced noticeable changes in health outcomes. L. C. Baker, S. J. Johnson, D. Macauley et al., "Integrated Telehealth and Care Management Program for Medicare Beneficiaries with Chronic Disease Linked to Savings," Health Affairs, Sept. 2011 30(9):1689–97. 

Checklists Increase Adherence to Preventive Health Guidelines
A study designed to determine the effectiveness of a checklist to improve the delivery of preventive health services at adult health check-ups found the intervention promoted the delivery of preventive health services by prompting physicians to follow evidence-based recommendations. Two of the four clinics studied used the checklist; in those clinics the percentage of up-to-date preventive health services delivered per patient at the end of the intervention was 71.7 percent, compared with 48.9 percent in the control group. Eight of 13 preventive health services showed a statistically significant change in favor of the intervention: counseling on brushing/flossing teeth, folic acid counseling, fecal occult blood testing, smoking cessation counseling, tetanus immunization, history of alcohol intake, history of smoking habits, and blood pressure measurement. E. R. Carrier, E. Schneider, H. H. Pham et al., "Association Between Quality of Care and the Sociodemographic Composition of Physicians' Patient Panels: A Repeat Cross-Sectional Analysis," Journal of General Internal Medicine, Sept. 2011 26(9):987–94. 

Hand Hygiene Program Reduces Length of Stay, Cost, and Mortality in Pediatric ICU
An effort to quantify the impact of strict hand hygiene practices on length of stay, costs, and mortality in a pediatric intensive care unit found that improving practices of hand hygiene, oral care, and central-line catheter care reduced hospital-acquired infections as well as mortality rates among children. In addition, on average patients admitted after the interventions were fully implemented spent 2.3 fewer days in the hospital, their hospitalization cost $12,136 less, and the mortality rate was 2.3 percentage points lower, compared with patients admitted before the interventions. The projected annual cost savings for the single pediatric intensive care unit studied was approximately $12 million, with modest expenses incurred for the improvements—which mainly consisted of posters for an educational campaign, a training "fair," roughly $21 per day for oral care kits, about $0.60 per day for chlorhexidine antiseptic patches, and hand sanitizers attached to the walls outside patients' rooms. B. D. Harris, C. Hanson, C. Christy et al., "Strict Hand Hygiene and Other Practices Shortened Stays and Cut Costs and Mortality in a Pediatric Intensive Care Unit," Health Affairs, Sept. 2011 30(9):1751–61. 

Alternative Quality Contract Reduces Spending Increases
A study looked at the effects of Blue Cross and Blue Shield of Massachusetts' Alternative Quality Contract, in which the health plan gave provider groups a global budget to cover the cost of delivering care to a defined population; providers benefit from controlling costs and earn bonuses for meeting quality targets. The researchers compared the claims for enrollees whose providers were working under the Alternative Quality Contract with those of enrollees whose providers were not. It found that average spending increased for enrollees in both the intervention and control groups in the first year, but that the increase was smaller (1.9% less) per quarter for enrollees in the intervention group. The savings were derived largely from shifts in outpatient care toward facilities with lower fees; from lower expenditures for procedures, imaging, and testing; and from a reduction in spending for enrollees with the highest expected spending. The contract was also associated with an improvement in performance on measures of the quality of the management of chronic conditions in adults and of pediatric care, but not of adult preventive care. Z. Song, D. Gelb Safran, B. E. Landon et al., "Health Care Spending and Quality in Year 1 of the Alternative Quality Contract," New England Journal of Medicine, Sept. 2011 365(10):909–18. 

Episode-Based Payment Models Face Hurdles
A commentary outlining the challenges of implementing episode-based payments—through which reimbursement for medical services is bundled together for defined episodes of care—suggests that for episode-based payments to be expanded beyond the experimentation stage, a number of barriers must be overcome, including the lack of standard methods for constructing "episodes," the need for reliable software to automate bundled payment, and the limited number of provider groups prepared to accept risk and manage clinical care. Two other significant barriers to broader use of this payment methodology are the reluctance of insurers to invest in software and systems and the challenge they face in attracting providers to participate in such programs. R. E. Mechanic, "Opportunities and Challenges for Episode-Based Payment," New England Journal of Medicine, Sept. 2011 365(9):777–79. 

EHRs Appear to Improve Diabetes Care
A study that compared achievement of and improvement in quality standards for diabetes at practices using electronic health records (EHRs) with those at practices using paper records found that achievement of composite standards for diabetes care was 35.1 percentage points higher at EHR sites than at paper-based sites and achievement of composite standards for outcomes was 15.2 percentage points higher. Across all insurance types (Medicare, commercial, Medicaid, or uninsured), EHR sites were associated with significantly higher achievement of care and outcome standards and greater improvement in diabetes care. The authors noted that the findings support the premise that federal policies encouraging meaningful uses of EHRs may improve the quality of care. R. D. Cebul, T. E. Love, A. K. Jain et al., "Electronic Health Records and Quality of Diabetes Care," New England Journal of Medicine, Sept. 2011 365(9):825–83. 

Patients Cared for by Hospitalists Have Higher Readmission Rates, ED Visits
A national study that compared the treatment of hospital patients cared for by hospitalists with those whose care was provided by primary care physicians found the former had a shorter length of stay but were less likely to be discharged to home; were less likely to see their primary care physician after discharge; and had more readmissions, emergency department visits, and nursing home visits after discharge. The study also found hospital cost savings associated with hospitalists were offset by increased medical utilization and costs after discharge. Y. Kuo and J. S. Goodwin, "Association of Hospitalist Care with Medical Utilization After Discharge: Evidence of Cost Shift from a Cohort Study," Annals of Internal Medicine, Aug. 2011 15(3):152–59. 

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