Publications of Note

The authors of a commentary in the American Journal of Medical Quality offer a counterpoint to several recent studies that have suggested there’s been little progress in the effort to increase patient safety in the United States. They point out that these studies have relied on the global trigger tools to measure harm rates, which have several significant limitations and are more appropriate for identifying risks at a single point in time rather than monitoring changes in safety over time. In addition to making recommendations for refinements in patient safety measures, the authors—two prominent experts in the field—note that a number of high-quality intervention studies involving teamwork training, simulation, bar coding, and practices for specific hazards such as falls have demonstrated marked improvements in patient safety. P. Pronovost and R. M. Wachter, “Progress in Patient Safety: A Glass Fuller Than It Seems American Journal of Medical Quality, March/April 2014 29(2):165–69. 

Disease Management Programs May Be Less Effective than Other Methods in Increasing Medication Adherence

Researchers comparing several value-based insurance design plans that lowered cost sharing to increase medication adherence found that plans that were more generous, targeted high-risk patients, offered wellness programs, did not offer disease management programs, and made the benefit available only for medication ordered by mail had a significantly greater impact on adherence than plans without these features. The authors had hypothesized that plans with a disease management program would have larger effects on adherence than plans without such a program, but when controlling for other characteristics, they found large and consistently negative effects on adherence linked to such programs. N. K. Choudhry, M. A. Fischer, B. F. Smith et al., “Five Features of Value-Based Insurance Design Plans Were Associated with Higher Rates of Medication Adherence,” Health Affairs, March 2014 33(3):493–501.

Variation in Readmission Risk Tied to Patient Characteristics, Not Hospital Ones

A study assessing the influence of patient characteristics, hospital characteristics, and provider type on hospital readmissions found that patients' characteristics are the largest contributor to variation in the risk of readmission among hospitals—explaining 56.2 percent of the variation. Measurable hospital characteristics and the type of inpatient provider contribute little to variation in risk of readmission among hospitals (0.84% and 9.3%, respectively). The study relied on data on admissions among Medicare beneficiaries to hospitals in Texas. S. Singh, Y. Lin, Y. Kuo et al., “Variation in the Risk of Readmission Among Hospitals: The Relative Contribution of Patient, Hospital and Inpatient Provider Characteristics,” Journal of General Internal Medicine, April 2014 29(4):572–78. 

Call for More Research on the Benefits of Patient-Focused Decision Support Tools 

A review of seven studies focusing on the potential of patient-focused decision support tools to generate savings found four projected system-wide savings ranging from $8 to $3,068 per patient, with larger savings attributed to lower utilization rates. The authors, however, note the risk of bias across the studies was moderate to high, with those predicting the most savings having the highest risk of bias. They identified other issue with the studies, including the relative absence of sensitivity analyses, the absence of incremental cost-effectiveness ratios, and short time periods, and concluded with the recommendation that further research be done to avoid unrealistic expectations that could jeopardize implementation and lead to the loss of the already proven benefits of such tools. T. Walsh, P. J. Barr, R. Thompson et al., “Undetermined Impact of Patient Decision Support Interventions on Healthcare Costs and Savings: Systematic Review,” BMJ, 2014 348:g188.

Composite Measure of Hospital Use Shows Decline Among Medicare Beneficiaries Between 2009 and 2013

A commentary in the Journal of the American Medical Association  notes that while hospitalization rates among Medicare beneficiaries have declined in recent years as observation stays have increased, a composite of the two measures indicates a decrease nationwide in hospital care between 2009 and 2013. The authors, two of whom are affiliated with the Centers for Medicare and Medicaid Services, say more research is needed to understand the drivers of this trend, but they suggest the results may reflect the efforts of CMS’ quality improvement organizations, the Partnership for Patients, and the Community-Based Care Transitions Program in reducing hospital use. G. W. Daughtridge, T. Archibald, and P. H. Conway, “Quality Improvement of Care Transitions and the Trend of Composite Hospital Care,” Journal of the American Medical Association, March 2014 311(10):1013–4. 

Limited Evidence of PCMHs' Effects in Improving Quality, Controlling Costs

A study designed to measure the association between the formation of patient-centered medical homes (PCMHs) in 32 primary care practices and changes in the quality, utilization, and costs of care found only limited improvements in quality and no association with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over three years. Pilot practices received disease registries and technical support and, over the three years, physicians accumulated average bonuses of $92,000 per primary care physician. The authors conclude that medical home interventions may need further refinement. M. W. Friedberg, E. C. Schneider, M. B. Rosenthal et al., “Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization, and Costs of Care,” Journal of the American Medical Association, Feb. 2014 311(8):815–25. 

A commentary in the Journal of the American Medical Association describes the potential of Medicare’s new bundled payments for hospitals, which will combine payment for services from three days prior to admission to 30 days after discharge. The Medicare Spending Per Beneficiary metric is designed to reward hospitals for avoiding unnecessary readmissions and increasing efficiency, while also encouraging greater coordination between inpatient and postacute care providers. The authors say the program will have a broader impact than Medicare’s accountable care initiatives because it will engage more providers in efforts to reevaluate patterns of discharge timing and assess the quality and cost of care at local skilled nursing facilities. C. Chen and D. C. Ackerly, “Beyond ACOs and Bundled Payments: Medicare’s Shift Toward Accountability in Fee-for-Service,” Journal of the American Medical Association, Feb. 2014 311(7):673–74. 

Readmission Rates for Patients Receiving Postacute Rehabilitation Vary by Impairment

A study of 30-day readmission rates among Medicare fee-for-service beneficiaries receiving postacute rehabilitation services found rates ranging from 5.8 percent with lower extremity joint replacement to 18.8 percent for patients with debility. Higher motor and cognitive functional status were associated with lower hospital readmission rates across six impairment categories: stroke, lower extremity fracture, lower extremity joint replacement, debility, neurologic disorders, and brain dysfunction. Heart failure, urinary tract infection, pneumonia, septicemia, nutritional and metabolic disorders, esophagitis, gastroenteritis, and digestive disorders were common reasons for readmission. K. J. Ottenbacher, A. Karmarkar, J. E. Graham et al., “Thirty-Day Hospital Readmission Following Discharge from Postacute Rehabilitation in Fee-for-Service Medicare Patients,” Journal of the American Medical Association, Feb. 2014 311(6):604–14. 

Health Information Exchanges Help Reduce Repeat Imaging in Emergency Departments

A study designed to evaluate whether broad-based electronic health information exchange (HIE) adoption is associated with decreases in repeat imaging for computed tomography (CT), ultrasound, and chest x-ray in emergency departments (EDs)—defined as a repeat image for a given patient in the same body region with 30 days at unaffiliated EDs—found HIE was associated with reduced probability of repeat ED imaging in all three modalities: −8.7 percentage points for CT, −9.1 percentage points for ultrasound, and −13.0 percentage points for chest x-ray. E. J. Lammers, J. Adler-Milstein, and K. E. Kocher, “Does Health Information Exchange Reduce Redundant Imaging? Evidence from Emergency Departments,” Medical Care, March 2014 52(3):227–34.

Range of Services in Hospitals Affects Surgical Mortality Rates

A study designed to assess whether hospital complexity—the range of services and technologies provided—affects outcomes, specifically inpatient surgical mortality, found hospital complexity is associated with lower mortality rates. The authors found patients receiving care at the hospitals in the lowest quintile of unique diagnoses had a 27 percent higher risk of death than those at the highest quintile. The effect of complexity was largest for low-volume hospitals, which were capable of achieving mortality rates similar to high-volume hospitals when in the most complex quintile. M. L. McCrum, S. R. Lipsitz, W. R. Berry et al., “Beyond Volume: Does Hospital Complexity Matters? An Analysis of Inpatient Surgical Mortality in the United States,” Medical Care, March 2014, 52(3):235–42.

Sequence in Which Symptoms of CAP Resolve Can Be Prognostic

The authors of this study examined the records of 1,326 patients with community-acquired pneumonia to determine whether the order in which six indicators of clinical instability (fever, tachycardia, tachypnea, hypotension, hypoxia, and altered medical status) resolved was predictive of outcomes and resource use. They found sequences of clinical instability resolution exhibit great heterogeneity, but certain sequence patterns are associated with differences in days to maximum stabilization, mortality, length of stay, and hospital costs. Some of the patterns do not appear to be deleterious in terms of 30-day mortality, and safe discharge with fever, tachycardia, or the combination of tachycardia and hypoxia may be possible for some patients with resulting shorter lengths of stay and lower hospitalization costs. However, when hypoxia or mental status instabilities are found in combination with other instabilities, the authors found higher levels of mortality, longer lengths of stay, and higher levels of resource utilization. G. W. Hougham , S. A. Ham, G. W. Ruhnke et al., “Sequence Patterns in the Resolution of Clinical Instabilities in Community-Acquired Pneumonia and Association with Outcomes,” Journal of General Internal Medicine, April 2014 29(4):563–71.

Effort to Assess Functional Outcome Data for Hip and Knee Replacement Detailed

The authors of this article describe the efforts of Gundersen Health System’s Orthopaedic Surgery Department to measure outcomes of care for patients having hip or knee arthroplasty procedures. The Hip Osteoarthritis Outcomes Score and Knee Osteoarthritis Outcomes Score, adapted from the Western Ontario and McMaster Universities Osteoarthritis Index, were collected preoperatively and one year after surgery to determine if patients were experiencing significant improvement on five outcome measures. The data demonstrated that the greatest improvements were noted in quality of life (48% reported improvement for hips and 37% for knees), while pain had the second greatest improvement (45% and 34%). A. M. Topel and C. A. Schini, “An Integrated Health Care System’s Approach to Development of a Process to Collect Patient Functional Outcomes on Total Joint Replacement Procedures," American Journal of Medical Quality, March/April 2014 29(2):160–64.