Health Care System Performance
Managing Surgical Wait Times
The authors compared strategies to manage surgical waiting times in Australia, Canada, England, New Zealand, and Wales. Most of these countries have allocated dedicated funding and set explicit waiting time targets in this area, and the most effective policies are highlighted. S. Willcox et al. (2007) Measuring and Reducing Waiting Times: A Cross-National Comparison of Strategies. Health Affairs 26, 1078–1087.
Insurer-Motivated Redesign Lowers Costs
An integrated delivery system's response to a threatened exclusion from an insurer's high-performance network is reviewed, including its attempt to reduce costs through a fundamental care process redesign. Although some features of this transformation are organization- and market-specific, other elements could be replicated. However, the authors conclude that making the business case for sustaining desirable provider behavior may require that purchasers and plans make equally fundamental changes in payment policy. H.H. Pham et al. (2007) Redesigning Care Delivery in Response to a High-Performance Network: The Virginia Mason Medical Center. Health Affairs 26, w532–w544.
Quality Reporting
HQA Indicators and Mortality
The authors examined the relationship between a hospital's performance on Hospital Quality Alliance (HQA) quality indicators and mortality for Medicare enrollees admitted for acute myocardial infarction, congestive heart failure, and pneumonia. They found that higher, condition-specific performance on the HQA indicators is associated with lower risk-adjusted mortality for each of the three conditions, validating the importance of this national hospital quality rating program. A.K. Jha et al. (2007) The Inverse Relationship between Mortality Rates and Performance in the Hospital Quality Alliance Measures. Health Affairs 26, 1104–1110.
Mortality Measures and End-of-Life Care
A commentary responding to the public release by CMS of hospital mortality rates concludes that mortality is a good quality measure for individuals with acute illness who are not supposed to die. But, according to the authors, it is a poor quality measure for most patients with multiple chronic diseases who are near the end of their life, as it treats death as a medical failure and reinforces avoiding death at all costs. R.G. Holloway and T.E. Quill. (2007) Mortality as a Measure of Quality: Implications for Palliative and End-of-Life Care. Journal of the American Medical Association 298, 802–804.
Quality Tools in Practice
QI: Evidence Needed
Increased interest in patient safety and health care quality has led to the implementation of innovative but unproven quality improvement (QI) strategies. The authors argue that these initiatives run counter to the principle of following the evidence in selecting interventions that meet quality and safety goals, as well as the idea that interventions should be tailored to local needs and resources. Thus, they recommend holding safety and quality interventions to the same standards that are applied to the adoption of all medical technologies. A.D. Auebach et al. (2007) The Tension between Needing to Improve Care and Knowing How to Do It. New England Journal of Medicine 357, 608–613.
National Initiative Improves HF Care
This study examined the effect of a national initiative to improve the care of patients hospitalized with heart failure, called the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF). Based on data from 259 U.S. hospitals (from March 1, 2003, to Dec. 31, 2004), the study found that OPTIMIZE-HF participation was associated with an increase in the use of evidence-based therapy, adherence to performance measures, and shorter lengths of stay for heart failure patients. G.C. Fonarow et al. (2007) Influence of a Performance-Improvement Initiative on Quality of Care for Patients Hospitalized With Heart Failure; Results of the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF). Archives of Internal Medicine 167, 1493–1502.
Pay-for-Performance
Proposal: New Payment Model for Medicare
This article proposes a new, blended payment strategy for Medicare that would combine fee-for-service payments with payments based on episodes of care. Transitioning to this payment model could take place in two stages, beginning with a pay-for-performance (P4P) payment system that rewards quality and efficiency and moving to a blended fee-for-service and case-rate system. Such a system, the authors conclude, would create incentives for providers to deliver both high-quality and efficient care. K. Davis and S. Guterman. (2007) Rewarding Excellence and Efficiency in Medicare Payments. The Milbank Quarterly 85, 449–468.
UK: P4P Led to "Modest" Improvements
Family practitioners' achievement under a P4P contract implemented in the United Kingdom three years ago exceeded the government's expectations, with an average of 83.4 percent of the available incentive payments claimed. This article reviews whether the 2004 contract or prior quality initiatives led to improvements in three conditions: asthma, coronary heart disease, and type 2 diabetes. Although care for these conditions was improving, the authors conclude that the introduction of P4P was associated with a modest acceleration in improvement for diabetes and asthma. S. Campbell et al. (2007) Quality of Primary Care in England with the Introduction of Pay for Performance. New England Journal of Medicine 357, 181–190.
Case-Rate Payment for CABG
Geisinger Health System's new approach to elective coronary-artery bypass grafting (CABG) promises that 40 key processes, agreed to by the seven cardiac surgeons in its delivery system, will be completed for every patient who undergoes elective CABG. According to the author, a member of Geisinger's board of directors, "the real question for Geisinger and for the rest of the health care system is whether this case-rate approach might emerge as a new form of pay for performance." T.H. Lee et al. (2007) Pay for Performance, Version 2.0? New England Journal of Medicine 357, 531–533.
Patient Safety
Pharmacies and Non-English Communication
A cross-sectional, mixed-methods survey of Milwaukee County, Wis., pharmacies was used to evaluate their ability to provide non-English-language prescription labels, information packets, and verbal communication. The authors found that about half of Milwaukee pharmacies never/only sometimes can provide non-English-language prescription labels or information packets, and about two-thirds never/only sometimes can verbally communicate in non-English languages. Also, only 55 percent of pharmacies said they were satisfied with their communication with patients who have limited English proficiency. M. Bradshaw et al. (2007) Language Barriers to Prescriptions for Patients with Limited English Proficiency: A Survey of Pharmacies. Pediatrics 120, e225–e235.
Study: Work Hour Limits Improve Outcomes
A retrospective cohort study was used to examine changes in internal medicine patient outcomes after resident work-hour regulations were implemented at an urban, academic medical center. It found that the teaching service had net improvements in three of the seven assessed outcomes: decreased intensive care unit utilization, improved rate of discharge to home or rehabilitation facility versus elsewhere, and reduced pharmacist interventions to prevent errors. L. I. Horwitz et al. (2007) Changes in Outcomes for Internal Medicine Inpatients after Work-Hour Regulations. Annals of Internal Medicine 147, 97–103.
Errors Increase Physician Anxiety
A survey, completed by 3,171 internal medicine, pediatrics, family medicine, and surgery physicians, examined the impact of medical errors on five work and life domains. After being involved in an error, physicians reported increased anxiety about future errors (61 percent), loss of confidence (44 percent), sleeping difficulties (42 percent), reduced job satisfaction (42 percent), and harm to their reputation (13 percent). Their job-related stress increased with involvement in serious errors, but this effect was less dramatic with near misses. The authors conclude that organizational resources to support physicians after errors should be improved. A.D. Waterman et al. (2007) The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada. Joint Commission Journal on Quality and Patient Safety 33, 467–476.
Managing Surgical Wait Times
The authors compared strategies to manage surgical waiting times in Australia, Canada, England, New Zealand, and Wales. Most of these countries have allocated dedicated funding and set explicit waiting time targets in this area, and the most effective policies are highlighted. S. Willcox et al. (2007) Measuring and Reducing Waiting Times: A Cross-National Comparison of Strategies. Health Affairs 26, 1078–1087.
Insurer-Motivated Redesign Lowers Costs
An integrated delivery system's response to a threatened exclusion from an insurer's high-performance network is reviewed, including its attempt to reduce costs through a fundamental care process redesign. Although some features of this transformation are organization- and market-specific, other elements could be replicated. However, the authors conclude that making the business case for sustaining desirable provider behavior may require that purchasers and plans make equally fundamental changes in payment policy. H.H. Pham et al. (2007) Redesigning Care Delivery in Response to a High-Performance Network: The Virginia Mason Medical Center. Health Affairs 26, w532–w544.
Quality Reporting
HQA Indicators and Mortality
The authors examined the relationship between a hospital's performance on Hospital Quality Alliance (HQA) quality indicators and mortality for Medicare enrollees admitted for acute myocardial infarction, congestive heart failure, and pneumonia. They found that higher, condition-specific performance on the HQA indicators is associated with lower risk-adjusted mortality for each of the three conditions, validating the importance of this national hospital quality rating program. A.K. Jha et al. (2007) The Inverse Relationship between Mortality Rates and Performance in the Hospital Quality Alliance Measures. Health Affairs 26, 1104–1110.
Mortality Measures and End-of-Life Care
A commentary responding to the public release by CMS of hospital mortality rates concludes that mortality is a good quality measure for individuals with acute illness who are not supposed to die. But, according to the authors, it is a poor quality measure for most patients with multiple chronic diseases who are near the end of their life, as it treats death as a medical failure and reinforces avoiding death at all costs. R.G. Holloway and T.E. Quill. (2007) Mortality as a Measure of Quality: Implications for Palliative and End-of-Life Care. Journal of the American Medical Association 298, 802–804.
Quality Tools in Practice
QI: Evidence Needed
Increased interest in patient safety and health care quality has led to the implementation of innovative but unproven quality improvement (QI) strategies. The authors argue that these initiatives run counter to the principle of following the evidence in selecting interventions that meet quality and safety goals, as well as the idea that interventions should be tailored to local needs and resources. Thus, they recommend holding safety and quality interventions to the same standards that are applied to the adoption of all medical technologies. A.D. Auebach et al. (2007) The Tension between Needing to Improve Care and Knowing How to Do It. New England Journal of Medicine 357, 608–613.
National Initiative Improves HF Care
This study examined the effect of a national initiative to improve the care of patients hospitalized with heart failure, called the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF). Based on data from 259 U.S. hospitals (from March 1, 2003, to Dec. 31, 2004), the study found that OPTIMIZE-HF participation was associated with an increase in the use of evidence-based therapy, adherence to performance measures, and shorter lengths of stay for heart failure patients. G.C. Fonarow et al. (2007) Influence of a Performance-Improvement Initiative on Quality of Care for Patients Hospitalized With Heart Failure; Results of the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF). Archives of Internal Medicine 167, 1493–1502.
Pay-for-Performance
Proposal: New Payment Model for Medicare
This article proposes a new, blended payment strategy for Medicare that would combine fee-for-service payments with payments based on episodes of care. Transitioning to this payment model could take place in two stages, beginning with a pay-for-performance (P4P) payment system that rewards quality and efficiency and moving to a blended fee-for-service and case-rate system. Such a system, the authors conclude, would create incentives for providers to deliver both high-quality and efficient care. K. Davis and S. Guterman. (2007) Rewarding Excellence and Efficiency in Medicare Payments. The Milbank Quarterly 85, 449–468.
UK: P4P Led to "Modest" Improvements
Family practitioners' achievement under a P4P contract implemented in the United Kingdom three years ago exceeded the government's expectations, with an average of 83.4 percent of the available incentive payments claimed. This article reviews whether the 2004 contract or prior quality initiatives led to improvements in three conditions: asthma, coronary heart disease, and type 2 diabetes. Although care for these conditions was improving, the authors conclude that the introduction of P4P was associated with a modest acceleration in improvement for diabetes and asthma. S. Campbell et al. (2007) Quality of Primary Care in England with the Introduction of Pay for Performance. New England Journal of Medicine 357, 181–190.
Case-Rate Payment for CABG
Geisinger Health System's new approach to elective coronary-artery bypass grafting (CABG) promises that 40 key processes, agreed to by the seven cardiac surgeons in its delivery system, will be completed for every patient who undergoes elective CABG. According to the author, a member of Geisinger's board of directors, "the real question for Geisinger and for the rest of the health care system is whether this case-rate approach might emerge as a new form of pay for performance." T.H. Lee et al. (2007) Pay for Performance, Version 2.0? New England Journal of Medicine 357, 531–533.
Patient Safety
Pharmacies and Non-English Communication
A cross-sectional, mixed-methods survey of Milwaukee County, Wis., pharmacies was used to evaluate their ability to provide non-English-language prescription labels, information packets, and verbal communication. The authors found that about half of Milwaukee pharmacies never/only sometimes can provide non-English-language prescription labels or information packets, and about two-thirds never/only sometimes can verbally communicate in non-English languages. Also, only 55 percent of pharmacies said they were satisfied with their communication with patients who have limited English proficiency. M. Bradshaw et al. (2007) Language Barriers to Prescriptions for Patients with Limited English Proficiency: A Survey of Pharmacies. Pediatrics 120, e225–e235.
Study: Work Hour Limits Improve Outcomes
A retrospective cohort study was used to examine changes in internal medicine patient outcomes after resident work-hour regulations were implemented at an urban, academic medical center. It found that the teaching service had net improvements in three of the seven assessed outcomes: decreased intensive care unit utilization, improved rate of discharge to home or rehabilitation facility versus elsewhere, and reduced pharmacist interventions to prevent errors. L. I. Horwitz et al. (2007) Changes in Outcomes for Internal Medicine Inpatients after Work-Hour Regulations. Annals of Internal Medicine 147, 97–103.
Errors Increase Physician Anxiety
A survey, completed by 3,171 internal medicine, pediatrics, family medicine, and surgery physicians, examined the impact of medical errors on five work and life domains. After being involved in an error, physicians reported increased anxiety about future errors (61 percent), loss of confidence (44 percent), sleeping difficulties (42 percent), reduced job satisfaction (42 percent), and harm to their reputation (13 percent). Their job-related stress increased with involvement in serious errors, but this effect was less dramatic with near misses. The authors conclude that organizational resources to support physicians after errors should be improved. A.D. Waterman et al. (2007) The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada. Joint Commission Journal on Quality and Patient Safety 33, 467–476.