Small Sample Sizes Provide Reliable Measures of Physician Performance
A study designed to determine the reliability of performance measurement for practice sites and individual physicians—as well as the sample sizes required to achieve reliability—found that a sample size of less than 200 patients was sufficient to assess individual physicians on measures of preventive care using the Health Care Effectiveness Data and Information Set (HEDIS), however the sample size was insufficient to assess HEDIS chronic care measures. At the practice site level, sample sizes of less than 200 patients were sufficient to assess four measures of preventive care, four process measures of diabetes care, and two outcome measures for diabetes care. The study also found that larger samples were required to achieve reliability for cholesterol screening in the presence of cardiovascular disease and use of appropriate asthma medications at the practice site level. T. D. Sequist, E. C. Schneider, A. Li et al., Reliability of Medical Group and Physician Performance Measurement in the Primary Care Setting, Medical Care, Feb. 2011 49(2):126–31.
Hospitals Not Going After Low-Hanging Fruit for Heart Failure and Pneumonia P4P Programs
A study designed to determine whether hospitals increase efforts on easy tasks relative to difficult tasks to improve scores under pay-for-performance programs found that hospitals did not do so for patients with heart failure or pneumonia, but did exhibit modestly greater effort on easy tasks for heart attack patients. L. H. Nicholas, J. B. Dimick and T. J. Iwashyna, Do Hospitals Alter Patient Care Effort Allocations Under Pay-for-Performance?, Health Services Research, Feb. 2011 46(1):61–81.
Performance Feedback and Use of Guidelines Reduce Overuse of Care
A California Medicaid managed care plan identified problematic variations in practice patterns involving the use of narcotics, muscle relaxants, magnetic resonance imaging, and spinal injections. To address them, a team of providers developed a strategy that relied on peer comparison data and respectful feedback to reduce overuse. The program resulted in the reversal of a trend, which showed the use for these medications and procedures was increasing at a rate between 8 percent and 18 percent per month. C. Cammisa, G. Patridge, C. Ardans et al., Engaging Physicians in Change: Results of a Safety Net Quality Improvement Program to Reduce Overuse, American Journal of Medical Quality Jan./Feb. 2011 26(1):26–33.
Higher-Volume Hospitals Have Better Heart Failure Outcomes
A study designed to assess whether hospitals with more experience in caring for heart failure patients provide better, more efficient care found that those with low volumes of such patients had lower performance on process measures (80.2 percent) than did medium-volume (87.0%) and high-volume hospitals (89.1%). The researchers also found that being admitted to a hospital with a higher case volume was associated with lower mortality, lower readmission rates, and higher costs. The researchers, who examined care at 4,095 U.S. hospitals, relied on Hospital Quality Alliance process measures for heart failure, 30-day, risk-adjusted mortality and readmission rates, and costs per discharge. Medicare claims data were used to assess the relationship between hospital case volume and quality, outcomes, and cost for these fee-for-service patients. K. E. Joynt, E. J. Orav, and A. K. Jha, The Association Between Hospital Volume and Processes, Outcomes, and Costs of Care for Congestive Heart Failure, Annals of Internal Medicine, Jan. 2010 154(2):94–102.
PGP Demonstration Provides Guidance for ACO Development
A commentary in the New England Journal of Medicine summarized results of the Physician Group Practice (PGP) Demonstration, which the Centers for Medicare and Medicaid Services developed to test whether care management initiatives would generate cost savings by reducing hospital admissions, readmissions, and emergency department visits, while improving quality. The PGP project is widely seen as a test-bed for accountable care organizations, which are designed to enable providers to share in the cost savings that ensue from quality improvement activities. J. K. Iglehart, Assessing an ACO Prototype—Medicare's Physician Group Practice Demonstration, New England Journal of Medicine Jan. 2011 364(3):198–200.
ACO Collaborative Provides Guidance Based on Early Experience
The Accountable Care Implementation Collaborative was launched in May 2010 to help participating health systems develop the capabilities necessary to operate an accountable care organization—an entity designed to encourage providers to improve quality and lower costs by sharing the savings that ensue from such efforts. This paper describes the focus of the participating health systems and their recommendations to policymakers about the need for broad-based measures of population health, as well as agreement on payment models between Medicare, Medicaid, and private payers and resolution of potential legal risks. S. DeVore and R. W. Champion, Driving Population Health Through Accountable Care Organizations, Health Affairs, Jan. 2011 30(1):41–50.
Relevance of Aviation Techniques to Patient Safety Strategies Debated
In a British Medical Journal piece, two anesthesiologists who are also pilots debated whether medicine has gone too far in translating ideas from aviation to patient safety. James Rogers, M.D., of the United Kingdom, argued that the aviation model has a limited place in medicine because the standardization of procedures is unrealistic in medicine, which involves more people with a varied skill mix who engage in different activities. David Gaba, M.D., of the United States, argues the analogy between medicine and aviation works well in instances involving sick patients with rapid clinical change, invasive procedures, and heavy use of technology. J. Rogers, Have We Gone Too Far in Translating Ideas from Aviation to Patient Safety? Yes, BMJ, Jan. 2011 342(7790): 198–9. And D. M. Gaba, Have We Gone Too Far in Translating Ideas from Aviation to Patient Safety? No, British Medical Journal, Jan. 2011 342(7790): 198–9.
Different Methodologies Produce Varying Hospital Mortality Rates
An initiative by the Massachusetts Division of Health Care Finance and Policy assessed methods used to calculate aggregate mortality measures. It found that four common methods for calculating hospital-wide mortality produced substantially different results. The state provided four vendors with identical information on 2.5 million discharges from Massachusetts hospitals between 2004 and 2007. The vendors used that data to predict probabilities of in-hospital deaths and hospital-level observed and expected mortality rates. The researchers analyzed the results, comparing the numbers and characteristics of the discharges and hospitals included, using each of the four methods. Two of the methods calculated in-hospital mortality rates (4.0% and 5.9%) that were twice the state average (2.1%). Predicted mortality probabilities ranged from 0.46 to 0.70. In 2006, 12 of 28 hospitals that had higher-than-expected hospital-wide mortality when classified by one method had lower-than-expected hospital-wide mortality when classified by one or more of the other methods. The researchers suggested several sources for the variation, including different statistical methods and fundamental flaws in the hypothesized association between hospital-wide mortality and quality of care. D. M. Shahian, R. E. Wolf, L. I. Iezzoni et al., Variability in the Measurement of Hospital-Wide Mortality Rates, New England Journal of Medicine, Dec. 2010 363(26):2530–9.
Trade-Off Between Costs and Mortality Identified Using VHA Data
Researchers examining the relationship between hospital costs and health outcomes for patients with acute myocardial infarction at Veterans Health Administration hospitals found that lower costs were negatively associated with mortality and readmissions. The study found that every $100 less spent is associated with a 0.64 percent increase in the hazard of dying and a 1.24 percent increase in the hazard of being readmitted. The results suggest a trade-off exists between costs and outcomes. The authors recommended that outcomes be closely monitored when introducing cost-containment programs. J. Schreyögg and T. Stargardt, The Trade-Off Between Costs and Outcomes: The Case of Acute Myocardial Infarction, Health Services Research Dec. 2010 45(6):1585–601.
For-Profit Hospital Status Linked to Rehospitalization Rates
A study of Medicare patients who were readmitted for acute care within 30 days of discharge from a different hospital found that the risk of rehospitalization increased if the index hospital was for-profit, affiliated with a major medical school, had a low volume of discharges, or was treating a patient who had Medicare disabled status. Compared with patients who were readmitted to the same hospital, patients who were readmitted at a different hospital had higher adjusted 30-day total payments (the median additional cost was $1,308 per patient), but no statistically significant differences in 30-day mortality, regardless of whether the index hospital had for-profit status. The study also found 22 percent of patients in the sample were rehospitalized in a different hospital. A. J. H. Kind, C. Bartels, M. W. Mell et al., For-Profit Hospital Status and Rehospitalizations at Different Hospitals: An Analysis of Medicare Data, Annals of Internal Medicine, Dec. 2010 153(11):718–27.
Composite Measures of Physician Performance Found Reliable
Researchers who investigated the feasibility, reliability, and validity of composite measures of physician performance on chronic care and preventive services found that reliabilities for composite measures expressed in a ratio were robust: 0.88 for chronic care and 0.87 for preventive services. (A score close to one implies high reliability.) The researchers also found that higher certification exam scores were associated with better performance. E. S. Holmboe, W. Weng, G. K. Arnold et al., The Comprehensive Care Project: Measuring Physician Performance in Ambulatory Practice, Health Services Research, Dec. 2010 45(6.2):1912–33.
Guidance on Proper Handoff Procedures Lacking
A review of research on handoffs in hospitals found that the research does not provide definitive conclusions on best handoff practices nor examples of marked gains in measured patient outcomes. Among other conclusions, the researchers noted that the term handoff and the meaning of standardization for handoffs are poorly defined. M. D. Cohen and P. B. Hilligoss, The Published Literature on Handoffs in Hospitals: Deficiencies Identified in an Extensive Review, Quality and Safety in Healthcare Dec. 2010 19(6):493–7.