Health Care System Performance
Improving U.S. Health Care: Lessons from Abroad
This position paper describes health care access, quality, and efficiency in the United States and compares the U.S. health system with those in other countries. The authors propose lessons to be learned from these countries and make recommendations for achieving a high-performance health care system. American College of Physicians (2008) Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries. Annals of Internal Medicine 148, 55–75.
Cost Containment
Value-Based Purchasing Limited
Researchers conducted telephone interviews with executives at 609 large businesses across 41 randomly selected U.S. markets between July 2005 and March 2006. Among the executives surveyed, 65 percent reported that they examine health plan quality data, but few reported using it for performance rewards (17%) or to influence employees (23%). The results showed that physician quality information is even less commonly examined (16%), used by employers to reward performance (2%), or influence employees' choice of providers (8%). M. B. Rosenthal et al. (2007) Employers' Use of Value-Based Purchasing Strategies. Journal of the American Medical Association 298, 2281–2288.
Paying for Medical Errors
Hospitals currently do not have a strong economic incentive to improve patient safety, as most of the costs of medical errors are shifted to other payers. This study analyzed 465 adverse events and found that, on average, the sampled hospitals generated injury-related costs of $2,013, and negligent-injury-related costs of $1,246, per discharge. However, the hospitals bore only 22 percent of the costs of all injuries and 30 percent of the costs of negligent injuries. The authors conclude that legal reforms or market interventions may be necessary to address this externalization of injury costs. M. M. Mello et al. (2007) Who Pays for Medical Errors? An Analysis of Adverse Event Costs, the Medical Liability System, and Incentives for Patient Safety Improvement. Journal of Empirical Legal Studies 4, 835–860.*
Hospitalists' Impact on Quality, Cost
A retrospective cohort study of 76,926 patients, hospitalized between September 2002 and June 2005, used multivariable models to compare the outcomes of care by 284 hospitalists, 993 general internists, and 971 family physicians. The study found that the hospitalist model was associated with a small reduction in length of stay for common inpatient diagnoses, without adversely affecting readmission or death rates. Costs were also modestly less when compared with general internists' care, but not significantly different from that provided by family physicians. P. K. Lindenauer et al. (2007) Outcomes of Care by Hospitalists, General Internists, and Family Physicians. New England Journal of Medicine 357, 2589–2600.
Patient Safety
Targeting Risky Drugs
This study estimated the number of and risk for emergency department visits for adverse events involving Beers criteria medications—a consensus-based list of medications identified as potentially inappropriate for use in older adults—compared with other medications. It found adverse events due to three other medications, warfarin, insulin, and digoxin, were 35 times greater than for those identified by Beers criteria. The authors conclude that, to maximize their impact, performance measures and interventions should target warfarin, insulin, and digoxin use. D. S. Budnitz et al. (2007) Medication Use Leading to Emergency Department Visits for Adverse Drug Events in Older Adults. Annals of Internal Medicine 147, 755–765.
Quality Reporting
Benchmarking Hospital Quality
Ventilator-associated pneumonia rates are increasingly being used to benchmark hospitals' performance and reward better care. However, accurate diagnosis of ventilator-associated pneumonia is challenging, and there is substantial subjectivity in the current surveillance definition. The authors conclude that ventilator-associated pneumonia should be excluded from compulsory reporting initiatives until objective outcome measures for these patients are validated. M. Klompas and R. Platt (2007) Ventilator-Associated Pneumonia—The Wrong Quality Measure for Benchmarking. Annals of Internal Medicine 147, 803–805.
Rating Doctors' Efficiency
As health care costs continue to increase and physicians make spending decisions for patients, purchasers have begun to look for ways to identify individual physicians who deliver good care most efficiently. Appropriate measures, and the proper use of such measurements, have been the focus of much debate between those who pay for health care and those who provide it. The authors conclude that physicians and consumers should collaborate to measure efficiency and encourage physicians to pursue lower-cost paths to the best clinical outcomes. A. Milstein and T. H. Lee (2007) Comparing Physicians on Efficiency. New England Journal of Medicine 357, 2649–2652.
Focusing P4P on Patients
Pay-for-performance initiatives that focus on a few specific elements of a single disease or condition may cause physicians to neglect patients as a whole, especially elderly patients with multiple chronic conditions. There are also concerns that such programs could result in the de-selection of patients, if providers "play to the measures." The authors conclude that, as this and other quality improvement initiatives evolve, they should put the needs and interests of patients first. L. Snyder and R. L. Neubauer for the American College of Physicians Ethics, Professionalism and Human Rights Committee (2007) Pay-for-Performance Principles that Promote Patient-Centered Care: An Ethics Manifesto. Annals of Internal Medicine 147, 792–794.
Quality Tools in Practice
Rapid Response for Pediatric Inpatients
A cohort study design, with historical controls, was used to evaluate the effect of introducing a rapid response team (RRT) on hospital-wide mortality rates and code rates outside of the ICU setting at an academic children's hospital. RRT members included a pediatric ICU–trained fellow or attending physician, ICU nurse, ICU respiratory therapist, and nursing supervisor. The study found that, after RRT implementation, the mean monthly mortality rate decreased by 18 percent, the mean monthly code rate per 1,000 admissions decreased by 71.7 percent, and the mean monthly code rate per 1,000 patient-days decreased by 71.2 percent. P. J. Sharek et al. (2007) Effect of a Rapid Response Team on Hospital-Wide Mortality and Code Rates Outside the ICU in a Children's Hospital. Journal of the American Medical Association 298, 2267–2274.
Improving Care for Stroke Patients
A nationwide, population-based study was used to examine the association between quality of care and mortality among patients with stroke. Based on an analysis of the seven selected criteria, the authors found an inverse dose-response relationship between the number of quality of care criteria met and mortality. Patients whose care met all criteria had the lowest mortality rate, suggesting that higher quality of care during the early phase of stroke is associated with substantially lower mortality rates. A. Ingeman (2008) Quality of Care and Mortality Among Patients with Stroke: A Nationwide Follow-up Study. Medical Care 46, 63–69.
RN Staffing Affects Outcomes
A review of 28 studies was used to examine the association between registered nurse (RN) staffing and patient outcomes in acute care hospitals. These studies showed associations between increased RN staffing and lower hospital-related mortality among patients in intensive care units (ICUs), surgical patients, and medical patients. Also, an increase of one RN per patient day was associated with a decreased odds ratio of hospital-acquired pneumonia, unplanned extubation, respiratory failure, and cardiac arrest in ICUs, and with a lower risk of failure to rescue in surgical patients. R. L. Kane et al. (2007) The Association of Registered Nurse Staffing Levels and Patient Outcomes: Systematic Review and Meta-Analysis. Medical Care 45, 1195–1204.
Summarizing Drug Evidence Increases Adherence
A cluster-randomized trial was used to examine the impact of having consultants write one-sentence evidence summaries—about medications they had recommended for patients with chronic disease—on discharge letters to primary care providers. The study found that appending the evidence summary decreased non-adherence to discharge medication from 29.6 percent to 18.5 percent, and that most clinicians were enthusiastic about receiving these summaries. R. Kunz et al. (2007) Impact of Short Evidence Summaries in Discharge Letters on Adherence of Practitioners to Discharge Medication. A Cluster-Randomised Controlled Trial. Quality and Safety in Health Care 16, 456–461.
* This Fund-supported article was published in a journal that is not routinely reviewed by Quality Matters editorial staff, and thus was not included on the list reviewed by the Editorial Advisory Board.
Improving U.S. Health Care: Lessons from Abroad
This position paper describes health care access, quality, and efficiency in the United States and compares the U.S. health system with those in other countries. The authors propose lessons to be learned from these countries and make recommendations for achieving a high-performance health care system. American College of Physicians (2008) Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries. Annals of Internal Medicine 148, 55–75.
Cost Containment
Value-Based Purchasing Limited
Researchers conducted telephone interviews with executives at 609 large businesses across 41 randomly selected U.S. markets between July 2005 and March 2006. Among the executives surveyed, 65 percent reported that they examine health plan quality data, but few reported using it for performance rewards (17%) or to influence employees (23%). The results showed that physician quality information is even less commonly examined (16%), used by employers to reward performance (2%), or influence employees' choice of providers (8%). M. B. Rosenthal et al. (2007) Employers' Use of Value-Based Purchasing Strategies. Journal of the American Medical Association 298, 2281–2288.
Paying for Medical Errors
Hospitals currently do not have a strong economic incentive to improve patient safety, as most of the costs of medical errors are shifted to other payers. This study analyzed 465 adverse events and found that, on average, the sampled hospitals generated injury-related costs of $2,013, and negligent-injury-related costs of $1,246, per discharge. However, the hospitals bore only 22 percent of the costs of all injuries and 30 percent of the costs of negligent injuries. The authors conclude that legal reforms or market interventions may be necessary to address this externalization of injury costs. M. M. Mello et al. (2007) Who Pays for Medical Errors? An Analysis of Adverse Event Costs, the Medical Liability System, and Incentives for Patient Safety Improvement. Journal of Empirical Legal Studies 4, 835–860.*
Hospitalists' Impact on Quality, Cost
A retrospective cohort study of 76,926 patients, hospitalized between September 2002 and June 2005, used multivariable models to compare the outcomes of care by 284 hospitalists, 993 general internists, and 971 family physicians. The study found that the hospitalist model was associated with a small reduction in length of stay for common inpatient diagnoses, without adversely affecting readmission or death rates. Costs were also modestly less when compared with general internists' care, but not significantly different from that provided by family physicians. P. K. Lindenauer et al. (2007) Outcomes of Care by Hospitalists, General Internists, and Family Physicians. New England Journal of Medicine 357, 2589–2600.
Patient Safety
Targeting Risky Drugs
This study estimated the number of and risk for emergency department visits for adverse events involving Beers criteria medications—a consensus-based list of medications identified as potentially inappropriate for use in older adults—compared with other medications. It found adverse events due to three other medications, warfarin, insulin, and digoxin, were 35 times greater than for those identified by Beers criteria. The authors conclude that, to maximize their impact, performance measures and interventions should target warfarin, insulin, and digoxin use. D. S. Budnitz et al. (2007) Medication Use Leading to Emergency Department Visits for Adverse Drug Events in Older Adults. Annals of Internal Medicine 147, 755–765.
Quality Reporting
Benchmarking Hospital Quality
Ventilator-associated pneumonia rates are increasingly being used to benchmark hospitals' performance and reward better care. However, accurate diagnosis of ventilator-associated pneumonia is challenging, and there is substantial subjectivity in the current surveillance definition. The authors conclude that ventilator-associated pneumonia should be excluded from compulsory reporting initiatives until objective outcome measures for these patients are validated. M. Klompas and R. Platt (2007) Ventilator-Associated Pneumonia—The Wrong Quality Measure for Benchmarking. Annals of Internal Medicine 147, 803–805.
Rating Doctors' Efficiency
As health care costs continue to increase and physicians make spending decisions for patients, purchasers have begun to look for ways to identify individual physicians who deliver good care most efficiently. Appropriate measures, and the proper use of such measurements, have been the focus of much debate between those who pay for health care and those who provide it. The authors conclude that physicians and consumers should collaborate to measure efficiency and encourage physicians to pursue lower-cost paths to the best clinical outcomes. A. Milstein and T. H. Lee (2007) Comparing Physicians on Efficiency. New England Journal of Medicine 357, 2649–2652.
Focusing P4P on Patients
Pay-for-performance initiatives that focus on a few specific elements of a single disease or condition may cause physicians to neglect patients as a whole, especially elderly patients with multiple chronic conditions. There are also concerns that such programs could result in the de-selection of patients, if providers "play to the measures." The authors conclude that, as this and other quality improvement initiatives evolve, they should put the needs and interests of patients first. L. Snyder and R. L. Neubauer for the American College of Physicians Ethics, Professionalism and Human Rights Committee (2007) Pay-for-Performance Principles that Promote Patient-Centered Care: An Ethics Manifesto. Annals of Internal Medicine 147, 792–794.
Quality Tools in Practice
Rapid Response for Pediatric Inpatients
A cohort study design, with historical controls, was used to evaluate the effect of introducing a rapid response team (RRT) on hospital-wide mortality rates and code rates outside of the ICU setting at an academic children's hospital. RRT members included a pediatric ICU–trained fellow or attending physician, ICU nurse, ICU respiratory therapist, and nursing supervisor. The study found that, after RRT implementation, the mean monthly mortality rate decreased by 18 percent, the mean monthly code rate per 1,000 admissions decreased by 71.7 percent, and the mean monthly code rate per 1,000 patient-days decreased by 71.2 percent. P. J. Sharek et al. (2007) Effect of a Rapid Response Team on Hospital-Wide Mortality and Code Rates Outside the ICU in a Children's Hospital. Journal of the American Medical Association 298, 2267–2274.
Improving Care for Stroke Patients
A nationwide, population-based study was used to examine the association between quality of care and mortality among patients with stroke. Based on an analysis of the seven selected criteria, the authors found an inverse dose-response relationship between the number of quality of care criteria met and mortality. Patients whose care met all criteria had the lowest mortality rate, suggesting that higher quality of care during the early phase of stroke is associated with substantially lower mortality rates. A. Ingeman (2008) Quality of Care and Mortality Among Patients with Stroke: A Nationwide Follow-up Study. Medical Care 46, 63–69.
RN Staffing Affects Outcomes
A review of 28 studies was used to examine the association between registered nurse (RN) staffing and patient outcomes in acute care hospitals. These studies showed associations between increased RN staffing and lower hospital-related mortality among patients in intensive care units (ICUs), surgical patients, and medical patients. Also, an increase of one RN per patient day was associated with a decreased odds ratio of hospital-acquired pneumonia, unplanned extubation, respiratory failure, and cardiac arrest in ICUs, and with a lower risk of failure to rescue in surgical patients. R. L. Kane et al. (2007) The Association of Registered Nurse Staffing Levels and Patient Outcomes: Systematic Review and Meta-Analysis. Medical Care 45, 1195–1204.
Summarizing Drug Evidence Increases Adherence
A cluster-randomized trial was used to examine the impact of having consultants write one-sentence evidence summaries—about medications they had recommended for patients with chronic disease—on discharge letters to primary care providers. The study found that appending the evidence summary decreased non-adherence to discharge medication from 29.6 percent to 18.5 percent, and that most clinicians were enthusiastic about receiving these summaries. R. Kunz et al. (2007) Impact of Short Evidence Summaries in Discharge Letters on Adherence of Practitioners to Discharge Medication. A Cluster-Randomised Controlled Trial. Quality and Safety in Health Care 16, 456–461.
* This Fund-supported article was published in a journal that is not routinely reviewed by Quality Matters editorial staff, and thus was not included on the list reviewed by the Editorial Advisory Board.