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Newsletter Article


Recent 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 Care System Performance

Greater Care Intensity Associated with Lower Patient Satisfaction, Quality
In order to examine associations among hospital care intensity, the technical quality of hospital care, and patients' ratings of their hospital experiences, the researchers linked the results of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and measures of technical process quality, both available on the Centers for Medicare and Medicaid Services Hospital Compare Web site, with data from the Dartmouth Atlas of Health Care. They found that greater inpatient care intensity was associated with lower quality scores and lower patient ratings, and lower quality scores were associated with lower patient ratings. In their conclusion, they wrote: "Our study suggests that efforts to encourage better coordination of care, rather than simply training more physicians or spending more money, holds the key to future health care reform." J. E. Wennberg, K. Bronner, J. S. Skinner et al., Inpatient Care Intensity and Patients' Ratings of Their Hospital Experiences , Health Affairs, Jan./Feb. 2009 28 (1): 103–112.

Publicly Reporting Hospital Scores Doesn't Affect Patients
A retrospective analysis, using the National Hospital Ambulatory Medical Care Survey, 2001-2005, assessed emergency department visits by adult patients with respiratory symptoms to determine whether public reporting has led to any unintended adverse consequences. It compared rates of pneumonia diagnosis, antibiotic use, and waiting times to see a physician before and after public reporting of hospital scores on antibiotic timing in pneumonia. The study found that such reporting has not led to increased pneumonia diagnosis, antibiotic use, or a change in patient prioritization. M. W. Friedberg, A. Mehrotra, and J. A. Linder, Reporting Hospitals' Antibiotic Timing in Pneumonia: Adverse Consequences for Patients?, American Journal of Managed Care, Feb. 15, 2009 15 (2): 137–144.

Quality Tools in Practice

Multidisciplinary Teams Needed to Manage Chronic Disease
The number of Americans with chronic illnesses is rising, and there is a striking gap between the high prevalence of chronic conditions among people living below the federal poverty level compared with the average prevalence in the general population. Evidence strongly suggests that multidisciplinary teams in primary care and public health are best suited to deliver higher-quality and lower-cost chronic and preventive care to this growing population. Yet, workforce projections indicate a growing number of specialist physicians per capita coupled with shortages of primary care clinicians and other multidisciplinary team members—leading the authors to suggest several "serious policy reforms" to prevent and manage chronic illness. T. Bodenheimer, E. Chen, and H. D. Bennett, Confronting the Growing Burden of Chronic Disease: Can the U.S. Health Care Workforce Do the Job? , Health Affairs, Jan./Feb. 2009 28 (1): 64–74.

Evidence Supports Chronic Care Model
Despite advances in treating chronic diseases, which are responsible for 59 percent of deaths and 46 percent of the global disease burden, many patients do not get the care they need. The Chronic Care Model aims to transform care for these patients from "acute and reactive to proactive, planned, and population-based." This paper reviews articles published since 2000 to examine the model's effectiveness. These studies show that, though more needs to be learned about the practicality, effectiveness, and cost implications of the Chronic Care Model, its use to guide practice redesign leads to improved patient care and better health outcomes. K. Coleman, B. T. Austin, C. Brach et al., Evidence on the Chronic Care Model in the New Millennium, Health Affairs, Jan./Feb .2009 28 (1): 75–85.

A Case for Chronic Disease Programs in Hospitals
While the Chronic Care Model and the patient-centered medical home have "worked around" the hospital and acute care system, the current funding environment largely provides acute care tools to deal with chronic disease. The authors conclude that there is a business case for hospitals to offer chronic disease programs customized to their local circumstances. Innovative chronic disease programs could be combined into a service line that would include prehospital, hospital, and posthospital programs. "Beyond benefits to hospitals, patients and payers could benefit from improved patient outcomes and costs; society could benefit from more appropriate deployment of resources," they write. A. L. Siu, L. H. Spragens, S. K. Inouye et al., The Ironic Business Case for Chronic Care in the Acute Care Setting, Health Affairs, Jan./Feb. 2009, 28 (1): 113–125.

Discharge Intervention Reduces Rehospitalization
A randomized trial was used to test whether additional discharge services could minimize emergency department visits and rehospitalization after patients are discharged. These services included a nurse discharge advocate who worked with patients during their stay to arrange follow-up appointments, confirm medication reconciliation, and conduct patient education, as well as a clinical pharmacist who followed up with patients to review medications. The study found that patients who received this intervention had lower hospitalization utilization. B. W. Jack, V. K. Chetty, D. Anthony et al., A Reengineered Hospital Discharge Program to Decrease Rehospitalization, Annals of Internal Medicine, Feb. 3, 2009 150 (3): 178–187.

Care Coordination Can Improve Chronic Care
Chronically ill Medicare beneficiaries were randomly assigned to intervention or control (usual care) groups to assess whether a care coordination program reduced hospitalizations and costs, and improved selected quality of care outcomes. Nurses contacted patients in the intervention group about two times a month, mostly via telephone, to improve treatment adherence and their ability to communicate with physicians. Thirteen of the 15 programs showed no significant differences in hospitalizations; none of the 15 programs generated net savings; three programs had lower monthly Medicare expenditures than the control group. The authors concluded that these programs are unlikely to yield net Medicare savings unless they have a strong transitional care component, and that substantial in-person contact can be cost-neutral and improve some aspects of care. D. Peikes, A. Chen, J. Schore et al., Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries: 15 Randomized Trials, Journal of the American Medical Association, Feb. 11, 2009 301 (6): 603–618.

Complaint Data: A New Analytical Tool for QI
This study assessed whether complaint data, which are available at a fraction of the cost of conducting patient satisfaction surveys, yield insights into an organization's performance. The authors found that analyzing the last 100 complaints (collected in a 50-day period) was sufficient to detect significant change in the processes of care. Because complaint data represent only very dissatisfied patients, as opposed to the reports of satisfied and dissatisfied patients to satisfaction surveys, more can be revealed about a unit's operations when both types of information are used. F. Alemi and P. Hurd, Rethinking Satisfaction Surveys: Time to Next Complaint, Joint Commission Journal on Quality and Patient Safety, Mar. 2009 35 (3): 156–161.

Health Care Costs

Rising Medical Costs Threaten Patient Trust in Physicians
A cross-sectional household survey, conducted largely by telephone, was used to examine the association between high medical cost burdens and self-reported measures of patients' trust in their providers and their perceptions of the quality of care. Adjusted analyses showed that patients with high medical cost burdens had greater odds of lacking trust that their physician will put their needs above all else and refer them to specialists when needed. They were also more likely to believe that physicians would perform unnecessary tests and had more negative assessments of the thoroughness of the care received. These associations were greatest for privately insured persons and, the authors conclude, have the potential to make health care delivery less effective. P. J. Cunningham, High Medical Cost Burdens, Patient Trust, and Perceived Quality of Care, Journal of General Internal Medicine, Mar. 2009 24 (3): 415–420.

Implementing QI for Depression Care Has High Upfront Costs
This study documented the organizational costs of a quality improvement project to develop an evidence-based depression care model for Veterans Health Administration primary care practices. This included time, salary costs, and costs for conference calls, meetings, e-mails, and other activities for a four-year period. It found that clinical participants spent 1,086 hours at a cost of $84,438, and technical experts spent 2,147 hours costing $197,787. The authors concluded that these costs—85 percent of which derived from initial regional engagement activities and care model design—were significant and should be accounted for when planning to implement evidence-based depression care. C.-F. Liu, L. V. Rubenstein, J. E. Kirchner et al., Organizational Cost of Quality Improvement for Depression Care, Health Services Research, Feb. 2009 44 (1): 225–244.

Prevention Adds More to Medical Costs than It Saves
This perspective reviews the evidence from 599 cost-effectiveness analysis studies, published between 2000 and 2005, that examined the costs and health outcomes of preventive care interventions. It found that less than 20 percent of the preventive options (and a similar percentage for treatment) fall in the cost-saving category; 80 percent add more to medical costs than they save. The author concludes that: "Careful choices about frequency, groups to target, and component costs can increase the likelihood that interventions will be highly cost-effective or even cost saving." L. B. Russell, Preventing Chronic Disease: An Important Investment, But Don't Count on Cost Savings, Health Affairs, Jan./Feb. 2009 28 (1): 42–45.

Traditional Medicare Presents Challenges to Disease Management
This study summarizes the results to date of seven disease demonstration and pilot programs conducted by Centers for Medicare and Medicaid Services (CMS) in fee-for-service Medicare, including the Medicare Health Support (MHS) pilot. It outlines CMS' interest in disease management, overviews the seven demonstrations, discusses demonstration-level results, and reviews CMS' future plans in this area. Among the findings is that it is challenging to reduce costs sufficient to cover program fees, including those that are provider-based, third-party, and hybrid models. D. M. Bott, M. C. Kapp, L. B. Johnson et al., Disease Management for Chronically Ill Beneficiaries in Traditional Medicare, Health Affairs, Jan./Feb. 2009 28 (1): 86–98.

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