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Recent Publications of Note

Measuring Performance

Survey: Generalist Concerns About P4P, Public Reporting

A national survey of general internists found strong potential support for financial incentives for quality, such as pay-for-performance (P4P), but less support for public reporting. Many respondents expect these programs will lead physicians to avoid high-risk patients and divert their attention from care for which quality is not measured. The authors conclude that public and private policymakers should consider these concerns when designing P4P and public reporting programs. L. P. Casalino et al. (2007) General Internists' Views on Pay-For-Performance and Public Reporting of Quality Scores: A National Survey. Health Affairs 26, 492–499.

Designing P4P to Reduce Disparities
Pay-for-performance (P4P) and public quality-reporting programs, in some cases, have the unintended consequence of increasing racial and ethnic disparities. The authors discuss ways to carefully design these programs so that they are more likely to reduce, or at least not to increase, disparities. L. P. Casalino and A. Elster (2007) Will Pay-For-Performance and Quality Reporting Affect Health Care Disparities? Health Affairs Web Exclusive, April 10, 2007.
Quality Tools in Practice

Cardiovascular Guidelines Improve Outcomes
A MEDLINE search was conducted to evaluate whether the use of performance measures derived from clinical practice guidelines is associated with better clinical outcomes for patients with cardiovascular disease. The studies that were examined varied considerably in design; still, the authors found "almost all studies showed a strong and 'dose-response' association between adherence to guidelines and performance measures and outcomes." R. H. Mehta et al. (2007) Performance Measures Have a Major Effect on Cardiovascular Outcomes: A Review. American Journal of Medicine 20, 398–402.

Collaboratives: Team Interactions Improve Performance
A telephone survey was used to evaluate the extent to which teams interact within multi-organizational, quality improvement collaboratives. Based on responses from 94 site teams in three collaboratives, 80 percent would contact another team again if they felt the need and 86 percent made a change as a direct result of these interactions. Also, teams typically exchanged tools such as software and interacted outside of planned activities; and having a large number of ties to other teams was found to be strongly related to being considered a leader by peers. The authors conclude that collaborative teams do exchange important information, and the social dynamics of the collaboratives contribute to individual and collaborative success. J. A. Marsteller et al. (2007) How Do Teams in Quality Improvement Collaboratives Interact? Joint Commission Journal on Quality and Patient Safety 33, 267–276.

Professional Interpreters Benefit LEP Patients
A systematic literature search identified articles about medical interpreters' impact on clinical care for patients with limited English proficiency (LEP). The effect of interpreter use on four clinical topics that were most likely to either impact or reflect disparities in health and health care was evaluated. The authors found that, in all four areas examined, use of professional interpreters is associated with improved clinical care more than is use of ad hoc interpreters, and professional interpreters appear to raise the quality of clinical care for LEP patients to approach or equal that for patients without language barriers. L. S. Karliner et al. (2007) Do Professional Interpreters Improve Clinical Care for Patients with Limited English Proficiency? A Systematic Review of the Literature. Health Services Research 42, 727–754.

Workgroup Drafts Ethical Principles for QI Research
Health care providers may inadvertently cause harm or deliver unequal treatment to patients while pursuing quality improvement (QI) activities, Yet, a workgroup of ethicists, clinicians, managers, regulators, and researchers convened by the Hastings Center, an independent bioethics research group, write in this article that such activities differ from human subjects research because they involve systematic, data-guided activities designed to bring about immediate improvements in particular settings. Thus, they propose ethical guidelines to protect participants in quality improvement research, but conclude that QI research should not have to undergo review by an institutional review board. J. Lynn et al. (2007) The Ethics of Using Quality Improvement Methods in Health Care. Annals of Internal Medicine146, 666–673.
Information Technology

Despite Computer Alerts, Some Patient Treatments Unchanged
Provider responses to computer alerts about guideline recommendations for patients with suboptimal hypertensive care were evaluated using a cross-sectional content analysis nested within a randomized, controlled trial. The authors found that clinical inertia was the primary reason for failing to engage in otherwise indicated treatment change for a subgroup of patients. C. L. Roumie et al. (2007) Clinical Inertia: A Common Barrier to Changing Provider Prescribing Behavior. Joint Commission Journal on Quality and Patient Safety 33, 277–285.
Error Identification and Prevention

"Enhanced" Hospital Occupancy May Increase Adverse Events
A random sample of 24,676 adult patients discharged from four U.S. hospitals was screened using administrative data to determine the relationship between peak hospital workload and rates of adverse events (AEs). "Enhanced" occupancy, same-day bed occupancy by more than one patient, was found to be related to the likelihood of AEs at one urban, teaching hospital. The authors conclude that hospitals operating at or over capacity may experience heightened rates of patient safety events. Further, they suggest that reengineering care structures might enable them to respond better during periods of high stress. J. S. Weissman et al. (2007) Hospital Workload and Adverse Events. Medical Care 45, 448–455.

Limited English Proficiency Increases Risk of Harm
To examine differences in the characteristics of adverse events between English-speaking patients and those with limited English proficiency, adverse event data were collected from six hospitals over seven months in 2005. About 49.1 percent of limited English proficient patient adverse events were found to involve some physical harm whereas only 29.5 percent of adverse events for patients who speak English resulted in physical harm. Adverse events affecting limited English proficient patients also resulted in a higher level of harm and were more likely to be the result of communication errors. C. Divi et al. (2007) Language Proficiency and Adverse Events in US Hospitals: A Pilot Study. International Journal for Quality in Health Care 19,60–67.

Intervention Reduces Prescription Errors
A prospective trial evaluated whether an outpatient intervention involving health care providers and their patients could reduce prescription medication reconciliation discrepancies. Standard care was compared with an intervention reconciliation process that included: letters reminding patients to bring medication bottles or lists to their visits, verification and correction of these lists in the patient's electronic medical record, and academic detailing and feedback on performance. The interventions were found to decrease prescription medication errors and average per-patient discrepancies, leading the authors to conclude that a multifaceted intervention influencing providers and patients is crucial to enhancing medication reconciliation. P. Varkey et al. (2007) Improving Medication Reconciliation in the Outpatient Setting. Joint Commission Journal on Quality and Patient Safety 33, 286–292.

Hospitals Develop Strategies to Eliminate POAEs
As part of Ascension Health's patient safety initiative, two sites developed and implemented five strategies to eliminate perioperative adverse events (POAEs): 1) prevention of errors due to human factors, 2) prevention of surgical site infections, 3) prevention of adverse perioperative cardiac events, 4) prevention of postoperative venous thromboembolism, and 5) prevention of postoperative hemorrhage. As a result of these efforts, Sacred Heart Hospital and Columbia St. Mary's both achieved ≥ 90% reduction in the POAE rate. H. Ewing et al. (2007) Eliminating Perioperative Adverse Events at Ascension Health. Joint Commission Journal on Quality and Patient Safety 33, 256–266.

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