Postdischarge Interviews Identify Errors
A random sample survey was used to determine whether postdischarge patient interviews could be used to detect adverse events that are not documented in the medical record. Among the 998 study patients, record review identified 11 serious, preventable events (1.1% of patients) and interviews identified an additional 21 serious and preventable events. The authors recommend that hospitals consider monitoring patient safety by adding questions about adverse events to postdischarge interviews. J. S. Weissman, E. C. Schneider, S. Weingart et al., Comparing Patient-Reported Hospital Adverse Events with Medical Record Review: Do Patients Know Something That Hospitals Do Not? Annals of Internal Medicine, July 15, 2008 149(2): 100–108.
Evaluating Medication Errors in Primary Care
This article abstracted and analyzed 194 medication-related errors using a medication error coding tool—Medication Error Types, Reasons, and Informatics Preventability (METRIP). The errors were voluntarily reported by more than 440 primary care clinicians and staff from 52 physician offices as part of two error reporting studies conducted by the American Academy of Family Physicians National Research Network. Among the medication errors, 126 (70%) were prescribing errors, 17 (10%) were medication administration errors, 17 (10%) were documentation errors, 13 (7%) were dispensing errors, and five (3%) were monitoring errors. More than half of the errors reached patients, and those that didn't were prevented by pharmacists, physicians, patients, and nurses. The authors conclude that 102 (57%) of the reported errors might have been prevented with enhanced electronic prescribing and monitoring tools. G. M. Kuo, R. L. Phillips, D. Graham et al., Medication Errors Reported by US Family Physicians and their Office Staff, Quality and Safety in Health Care, Aug. 2008 17: 286–290.
Physician and Nurse Reports of Errors Vary
This descriptive study of a standardized, electronic error reporting system (e-ERS) compared the reporting practices of physicians and nurses at 29 acute care hospitals and one long-term care organization. These institutions implemented a secure, Web-based portal, available on all hospital computers, between August 2000 and December 2005—and reported some 266,224 events over 7.3 million inpatient days, or one event per 27.5 days. Physicians reported 1.1 percent of total events, nurses 45.3 percent, and other hospital employees 53.6 percent, with physicians more likely to be the reporter for events that caused permanent harm, near death, or death of a patient. The authors conclude that physicians should be encouraged to increase their reporting of adverse events. E. J. Rowin, D. Lucier, S. G. Pauker et al., Does Error and Adverse Event Reporting by Physicians and Nurses Differ? Joint Commission Journal on Quality and Patient Safety, Sept. 2008 34(9): 537–545.
Creating Measures Without Negative Consequences
Though improving health care quality depends on measurement, few quality outcome measures have been validated. The quality standard measuring time to first antibiotic dose for patients presenting to a hospital with community-acquired pneumonia, for example, was recently revised to six hours from four hours. This resulted from criticism that the original standard pressured clinicians to rapidly administer antibiotics despite diagnostic uncertainty. The authors conclude that missteps like this will happen, but recommend taking actions to increase the probability that future publicly reported quality measures improve care without creating unintended and potentially negative consequences. R. M. Wachter, S. A. Flanders, C. Fee et al., Public Reporting of Antibiotic Timing in Patients with Pneumonia: Lessons from a Flawed Performance Measure, Annals of Internal Medicine, July 1, 2008 149(1): 29–32.
Quality Indicators for Inpatient Pediatric Care
Agency for Healthcare Research and Quality quality indicators were adapted for use with a pediatric population and rated by four expert panels through a two-stage modified Delphi process. This process identified 18 indicators for inclusion in the pediatric quality indicator set, including 13 hospital-level indicators, with 11 based on complications, one based on mortality, and one based on volume, as well as five area-level potentially preventable hospitalization indicators. The authors conclude that using these indicators to track "potentially preventable complications and hospitalizations has the potential to help prioritize quality improvement efforts at both local and national levels, although additional validation research is needed to confirm the accuracy of coding." K. M. McDonald, S. M. Davies, C. A. Haberland et al., Preliminary Assessment of Pediatric Health Care Quality and Patient Safety in the United States Using Readily Available Administrative Data, Pediatrics, Aug. 2008 122(2): e416–e425.
Financial Incentives for Quality
Evaluating P4P's Effect on Quality
This study evaluated the impact on quality of all pay-for-performance (P4P) programs introduced into physician group contracts by the five major commercial health plans operating in Massachusetts from 2001 to 2003. It found that the initial generation of P4P contracts may have lacked key ingredients necessary to have a notable impact on quality performance. However, the authors conclude that "P4P can be viewed as an integral part of recent changes to medical practice that also include public reporting of quality, tiering of physician networks, and other mechanisms that create an explicit or implicit link between physician performance and future income." They also recommend future research to explore whether changes to the magnitude, structure, or alignment of P4P incentives can lead to improved quality. S. D. Pearson, E. C. Schneider, K. P. Kleinman et al., The Impact of Pay-for-Performance on Health Care Quality in Massachusetts, 2001–2003, Health Affairs, July/Aug. 2008 27(4): 1167–1176.
Expanded and Affordable Health Care Reform
This article reviews the need for comprehensive health care reform to require proposals that both expand coverage and redesign the delivery system so as to achieve greater value for the increased investment. To address this challenge, the authors propose five different accountable care system (ACS) models, defined as entities "that can implement organized processes for improving the quality and controlling the costs of care and be held accountable for the results." Though few physician organizations currently have the capacity to manage both quality and costs, they believe that the number of ACSs could increase rapidly if "incentives for improving quality and efficiency become more widespread and of greater magnitude." S. M. Shortell and L. P. Casalino, Health Care Reform Requires Accountable Care Systems, Journal of the American Medical Association, July 2, 2008 300(1): 95–97.
MedPAC Recommends Bundled Payment for Medicare
The authors review three recommendations from the Medicare Payment Advisory Commission (MedPAC) June report intended to create collective accountability across providers for selected hospital episodes, such as those for congestive heart failure, chronic obstructive pulmonary disease, and cardiac bypass surgery. "Our hope is that this set of policies will create an environment that encourages and enables providers to accept bundled payments while also testing the feasibility of this payment design. Under a bundled payment approach, Medicare would pay a single provider entity (comprising a hospital and its affiliated physicians) a fixed amount intended to cover the costs of providing the full range of Medicare-covered services delivered during the episode, which might be defined as the hospital stay plus 30 days after discharge. Bundling payments in this way should provide incentives to increase efficiency, coordinate in-hospital and post-hospital care, and, if combined with pay-for-performance initiatives, improve the quality of care." G. Hackbarth, R. Reischauer, and A. Mutti, Collective Accountability for Medical Care—Toward Bundled Medicare Payments, New England Journal of Medicine, July 3, 2008 359(1): 3–5.
Using Cost-Effectiveness Analysis to Evaluate Payment Models
This study sought to demonstrate the use of cost-effectiveness analysis for evaluating different reimbursement models, using cases of Medicaid patients with severe mental illness. The authors compared the cost-effectiveness of fee-for-service payments with capitation payments (both for-profit and not-for-profit models). They identified cases that minimized baseline differences across the groups and reported quality-adjusted life years for each group. Based on this analysis, the authors concluded that a capitation model with a for-profit element was more cost-effective for Medicaid patients with severe mental illness than not-for-profit capitation or fee-for-service models. R. Grieve, J. S. Sekhon, T. Hu et al., Evaluating Health Care Programs by Combining Cost with Quality of Life Measures: A Case Study Comparing Capitation and Fee for Service, Health Services Research, Aug. 2008 43(4): 1204–1222.
Quality Tools in Practice
Reducing Outpatient Antibiotic Prescribing
A systematic review and quantitative literature analysis was used to assess the effectiveness of quality improvement (QI) strategies to reduce antibiotic prescribing in the ambulatory care setting. Among the 30 identified trials that were found to be eligible for quantitative analysis, the median reduction in the proportion of subjects receiving antibiotics was 9.7 percent over six months median follow-up. Although no single QI strategy or combination of strategies was clearly superior, active clinician education strategies trended toward greater effectiveness than passive strategies, and broad-based interventions extrapolated to larger community-level impacts on total antibiotic use, compared with studies targeting specific conditions or patient populations. S. R. Ranji, M. A. Steinman, K. G. Shojania et al., Interventions to Reduce Unnecessary Antibiotic Prescribing: A Systematic Review and Quantitative Analysis, Medical Care, Aug. 2008 46(8): 847–862.
Report Card's Effect on Nursing Home Quality
This study analyzed primary and secondary data from 2001 to 2003—including 701 survey responses of a random sample of nursing homes, the Minimum Data Set (MDS) with information about all residents in these facilities, and the Nursing Home Compare published quality measure scores—to examine associations between the quality of care in nursing homes and publication of the Nursing Home Compare quality report card. The authors found two of the five quality measures showed improvement following publication of the report card, suggesting that report cards may motivate providers to improve quality and raising questions as to why this tool is not effective across the board. D. B. Mukamel, D. L. Weimer, W. D. Spector et al., Publication of Quality Report Cards and Trends in Reported Quality Measures in Nursing Homes, Health Services Research, Aug. 2008 43(4): 1244–1262.
Hospitalist and Non-Hospitalist Heart Failure Care Quality Similar
This study used data from the Multicenter Hospitalist Study to retrospectively evaluate quality of care in patients admitted with heart failure who were assigned to hospitalists (n=120) or non-hospitalists (n=252) among six academic hospitals. It found that, compared with non-hospitalist physicians, hospitalists' patients had similar rates of ejection fraction measurement (85.3% vs. 87.5%), angiotension-converting enzyme inhibitor (ACE-I) (91.5% vs. 88%), or beta-blocker (46.9% vs. 42.1%) prescriptions; they also had high odds of 30-day follow-up. However, there were no significant differences between the groups' frequency of cardiac testing, length of stay, costs, or risk for readmission or death by 30-days. The authors conclude that academic hospitalists and non-hospitalists provide similar quality of care for heart failure patients, and recommend that "future efforts to improve quality may require attention towards system-level factors." E. E. Vasilevskis, D. Meltzer, J. Schnipper et al., Quality of Care for Decompensated Heart Failure: Comparable Performance Between Academic Hospitalists and Non-Hospitalists, Journal of General Internal Medicine, Sept. 2008 23(9): 1399–1406.