Health Care System Performance
Health Plans: Organizational Form and Performance
A multivariate regression cross-sectional analysis of 272 health plans was used to evaluate the relationship of health plan characteristics—including the percentage of care provided based on a group or staff model delivery system, for-profit (tax) status, and affiliation with a national managed care firm—to measures of clinical performance and patient perceptions of care. The results suggest that the type of delivery system used by health plans is related to many clinical performance measures but is not related to patient perceptions of care. According to the authors, these findings underscore the importance of delivery system design and the need for further research on the relationship between organizational form and performance. R. R. Gillies et al. (2006) The Impact of Health Plan Delivery System Organization on Clinical Quality and Patient Satisfaction Health Services Research 41, 1181–1199.
Do AMI Measures Correlate With Performance?
This study assessed hospital performance in the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) quality process measures for acute myocardial infarction (AMI) and correlated these measures with each other and with hospital-level, risk-standardized, 30-day mortality rates derived from Medicare claims data. The authors found that publicly reported AMI process measures capture a small proportion of the variation in hospitals' risk-standardized short-term mortality rates. They concluded that multiple measures reflecting a variety of processes as well as outcomes, such as risk-standardized mortality rates, are needed to more fully characterize hospital performance. E. H. Bradley et al. (2006) Hospital Quality for Acute Myocardial Infarction: Correlation Among Process Measures and Relationship with Short-term Mortality Journal of the American Medical Association 296, 72–78.
Quality Reporting
Quality Measurement in Obstetrics
Three new obstetrical quality improvement outcome tools were developed to benchmark ongoing care within and among organizations. The Adverse Outcome Index is the percent of deliveries with one or more adverse events; the Weighted Adverse Outcome Score describes the adverse event score per delivery; and the Severity Index describes the severity of the outcomes. The authors conclude that these tools may be useful nationally for determining quality obstetric care, which lacks a nationally accepted set of quality indicators. S. Mann et al. (2006) Assessing Quality in Obstetrical Care: Development of Standardized Measures Joint Commission Journal on Quality and Patient Safety 32, 497–505.
Quality Tools in Practice
QIOs Appear to Improve Care
This observational study evaluated the effect of the Medicare Quality Improvement Organization (QIO) program in four clinical settings—nursing homes, home health agencies, hospitals, and physician offices. Performance data for 41 quality measures were compared between baseline and remeasurement periods for providers that received different levels of QIO interventions. The authors, while noting the study's limitations, found improvement in 34 of 41 measures among the clinical settings receiving focused QIO assistance. A related editorial reviewing the analysis concludes that "although several performance indicators improved in desired directions, we do not know why and we cannot be sure that such improvement stemmed from the QIO interventions." W. Rollow et al. (2006) Assessment of the Medicare Quality Improvement Organization Program Annals of Internal Medicine 145, 342–353; S. M. Shortell and W. A. Peck (2006) Enhancing the Potential of Quality Improvement Organizations to Improve Quality of Care Annals of Internal Medicine 145, 388–389.
Disease Management: Effective for Diabetics?
This cross-sectional study evaluated whether disease management by physician groups is associated with diabetes care processes, control of intermediate outcomes, or the amount of medication used when intermediate outcomes are above target levels. It found that disease management strategies were associated with better processes of diabetes care but not with improved intermediate outcomes or level of medication management. The authors concluded that a greater focus on direct measurement, feedback, and reporting of intermediate outcome levels or of level of medication management may enhance the effectiveness of these programs. C. M. Mangione et al. (2006) The Association Between Quality of Care and the Intensity of Diabetes Disease Management Programs Annals of Internal Medicine 145, 107–116.
Improving Treatment for COPD Patients
A retrospective cohort study was used to evaluate the quality of care provided to patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease (COPD) and determine whether hospital or patient characteristics influence treatment. It found 66 percent of the 69,820 patients studied received the entire set of recommended care processes contained in guidelines produced by the American College of Physicians and the American College of Chest Physicians. However, numerous participants received tests or treatments that were not beneficial, and individual hospital performance varied widely. The authors concluded that quality of care for these patients may be improved by increasing the use of systemic corticosteroid and antibiotic therapy, decreasing the use of unnecessary and potentially harmful treatments, and reducing variation in practice across hospitals. P. K. Lindenauer et al. (2006) Quality of Care for Patients Hospitalized for Acute Exacerbations of Chronic Obstructive Pulmonary Disease Annals of Internal Medicine 144, 894–903.
QI Strategies' Effect on Glycemic Control
This study assessed the impact of 11 distinct strategies for quality improvement (QI) on glycemic control in adults with type 2 diabetes. It found most QI strategies produced small to modest improvements in glycemic control, with team changes and case management showing more robust improvements—especially for interventions in which case managers could adjust medications without awaiting physician approval. Estimates of the effectiveness of other specific QI strategies may have been limited by difficulty in classifying complex interventions, insufficient numbers of studies, and publication bias. K. G. Shojania et al. (2006) Effects of Quality Improvement Strategies for Type 2 Diabetes on Glycemic Control: A Meta-Regression Analysis Journal of the American Medical Association 296, 427–440.
Error Identification and Prevention
Patient Response to Error Disclosure
This study sought to determine whether full disclosure, an existing positive physician–patient relationship, an offer to waive associated costs, and the severity of the clinical outcome influence patients' responses to medical errors. It found that full disclosure is likely to have a positive effect or no effect on how patients respond to medical errors. However, the impact of an existing positive physician–patient relationship or waiving costs associated with the error, remains uncertain. K. M. Mazor et al. (2006) Disclosure of Medical Errors: What Factors Influence How Patients Respond? Journal of General Internal Medicine 21, 704–710.
Pay-for-Performance
Linking Payment to Performance
A systematic literature review found few empirical studies assessing the effect of explicit financial incentives for improved performance on measures of health care quality were available. Among those identified, 13 of 17 studies examined process-of-care quality measures. Five of the six studies of physician-level financial incentives and seven of the nine studies of provider group-level financial incentives found partial or positive effects on measures of quality. One of the two studies of incentives at the payment-system level found a positive effect on access to care, and one showed evidence of a negative effect on access to care for the sickest patients. The authors conclude that ongoing monitoring is critical to evaluate the effectiveness of financial incentives. L. A. Petersen et al. (2006) Does Pay-for-Performance Improve the Quality of Health Care? Annals of Internal Medicine 145, 265–272.
UK's Experience: The First Year of the P4P Contract
This article and related editorial evaluate the experience of family practitioners in the first year of the United Kingdom's National Health Service pay-for-performance contract. Introduced in 2004, this contract increases existing income according to performance with respect to 146 quality indicators covering clinical care for 10 chronic diseases, organization of care, and patient experience. The authors found English family practices attained high levels of achievement, but a small number of practices appear to have achieved high scores by excluding large numbers of patients through exception reporting. They conclude that more research is needed to determine whether these practices are excluding patients for sound clinical reasons or in order to increase income. T. Doran et al. (2006) Pay-for-Performance Programs in Family Practices in the United Kingdom New England Journal of Medicine 355, 375–384; A. M. Epstein (2006) Paying for Performance in the United States and Abroad New England Journal of Medicine 355, 406–408.
Older Adults
Colonoscopy: Does Medicare Coverage Decrease Disparities?
This article examined the effect of Medicare reimbursement of colonoscopy for average-risk beneficiaries on the rates of colorectal cancer screening among the elderly in the United States. The authors found this policy, effective July 2001, alleviated the screening disparity between non-Hispanic whites and blacks, but the gap between Hispanics and non-Hispanic whites has widened. Overall, fewer than half of the elderly are screened, even though Medicare now covers colonoscopy. Y. T. Shih et al. (2006) Does Medicare Coverage of Colonoscopy Reduce Racial/Ethnic Disparities in Cancer Screening Among the Elderly? Health Affairs 25, 1153–1162.
Health Plans: Organizational Form and Performance
A multivariate regression cross-sectional analysis of 272 health plans was used to evaluate the relationship of health plan characteristics—including the percentage of care provided based on a group or staff model delivery system, for-profit (tax) status, and affiliation with a national managed care firm—to measures of clinical performance and patient perceptions of care. The results suggest that the type of delivery system used by health plans is related to many clinical performance measures but is not related to patient perceptions of care. According to the authors, these findings underscore the importance of delivery system design and the need for further research on the relationship between organizational form and performance. R. R. Gillies et al. (2006) The Impact of Health Plan Delivery System Organization on Clinical Quality and Patient Satisfaction Health Services Research 41, 1181–1199.
Do AMI Measures Correlate With Performance?
This study assessed hospital performance in the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) quality process measures for acute myocardial infarction (AMI) and correlated these measures with each other and with hospital-level, risk-standardized, 30-day mortality rates derived from Medicare claims data. The authors found that publicly reported AMI process measures capture a small proportion of the variation in hospitals' risk-standardized short-term mortality rates. They concluded that multiple measures reflecting a variety of processes as well as outcomes, such as risk-standardized mortality rates, are needed to more fully characterize hospital performance. E. H. Bradley et al. (2006) Hospital Quality for Acute Myocardial Infarction: Correlation Among Process Measures and Relationship with Short-term Mortality Journal of the American Medical Association 296, 72–78.
Quality Reporting
Quality Measurement in Obstetrics
Three new obstetrical quality improvement outcome tools were developed to benchmark ongoing care within and among organizations. The Adverse Outcome Index is the percent of deliveries with one or more adverse events; the Weighted Adverse Outcome Score describes the adverse event score per delivery; and the Severity Index describes the severity of the outcomes. The authors conclude that these tools may be useful nationally for determining quality obstetric care, which lacks a nationally accepted set of quality indicators. S. Mann et al. (2006) Assessing Quality in Obstetrical Care: Development of Standardized Measures Joint Commission Journal on Quality and Patient Safety 32, 497–505.
Quality Tools in Practice
QIOs Appear to Improve Care
This observational study evaluated the effect of the Medicare Quality Improvement Organization (QIO) program in four clinical settings—nursing homes, home health agencies, hospitals, and physician offices. Performance data for 41 quality measures were compared between baseline and remeasurement periods for providers that received different levels of QIO interventions. The authors, while noting the study's limitations, found improvement in 34 of 41 measures among the clinical settings receiving focused QIO assistance. A related editorial reviewing the analysis concludes that "although several performance indicators improved in desired directions, we do not know why and we cannot be sure that such improvement stemmed from the QIO interventions." W. Rollow et al. (2006) Assessment of the Medicare Quality Improvement Organization Program Annals of Internal Medicine 145, 342–353; S. M. Shortell and W. A. Peck (2006) Enhancing the Potential of Quality Improvement Organizations to Improve Quality of Care Annals of Internal Medicine 145, 388–389.
Disease Management: Effective for Diabetics?
This cross-sectional study evaluated whether disease management by physician groups is associated with diabetes care processes, control of intermediate outcomes, or the amount of medication used when intermediate outcomes are above target levels. It found that disease management strategies were associated with better processes of diabetes care but not with improved intermediate outcomes or level of medication management. The authors concluded that a greater focus on direct measurement, feedback, and reporting of intermediate outcome levels or of level of medication management may enhance the effectiveness of these programs. C. M. Mangione et al. (2006) The Association Between Quality of Care and the Intensity of Diabetes Disease Management Programs Annals of Internal Medicine 145, 107–116.
Improving Treatment for COPD Patients
A retrospective cohort study was used to evaluate the quality of care provided to patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease (COPD) and determine whether hospital or patient characteristics influence treatment. It found 66 percent of the 69,820 patients studied received the entire set of recommended care processes contained in guidelines produced by the American College of Physicians and the American College of Chest Physicians. However, numerous participants received tests or treatments that were not beneficial, and individual hospital performance varied widely. The authors concluded that quality of care for these patients may be improved by increasing the use of systemic corticosteroid and antibiotic therapy, decreasing the use of unnecessary and potentially harmful treatments, and reducing variation in practice across hospitals. P. K. Lindenauer et al. (2006) Quality of Care for Patients Hospitalized for Acute Exacerbations of Chronic Obstructive Pulmonary Disease Annals of Internal Medicine 144, 894–903.
QI Strategies' Effect on Glycemic Control
This study assessed the impact of 11 distinct strategies for quality improvement (QI) on glycemic control in adults with type 2 diabetes. It found most QI strategies produced small to modest improvements in glycemic control, with team changes and case management showing more robust improvements—especially for interventions in which case managers could adjust medications without awaiting physician approval. Estimates of the effectiveness of other specific QI strategies may have been limited by difficulty in classifying complex interventions, insufficient numbers of studies, and publication bias. K. G. Shojania et al. (2006) Effects of Quality Improvement Strategies for Type 2 Diabetes on Glycemic Control: A Meta-Regression Analysis Journal of the American Medical Association 296, 427–440.
Error Identification and Prevention
Patient Response to Error Disclosure
This study sought to determine whether full disclosure, an existing positive physician–patient relationship, an offer to waive associated costs, and the severity of the clinical outcome influence patients' responses to medical errors. It found that full disclosure is likely to have a positive effect or no effect on how patients respond to medical errors. However, the impact of an existing positive physician–patient relationship or waiving costs associated with the error, remains uncertain. K. M. Mazor et al. (2006) Disclosure of Medical Errors: What Factors Influence How Patients Respond? Journal of General Internal Medicine 21, 704–710.
Pay-for-Performance
Linking Payment to Performance
A systematic literature review found few empirical studies assessing the effect of explicit financial incentives for improved performance on measures of health care quality were available. Among those identified, 13 of 17 studies examined process-of-care quality measures. Five of the six studies of physician-level financial incentives and seven of the nine studies of provider group-level financial incentives found partial or positive effects on measures of quality. One of the two studies of incentives at the payment-system level found a positive effect on access to care, and one showed evidence of a negative effect on access to care for the sickest patients. The authors conclude that ongoing monitoring is critical to evaluate the effectiveness of financial incentives. L. A. Petersen et al. (2006) Does Pay-for-Performance Improve the Quality of Health Care? Annals of Internal Medicine 145, 265–272.
UK's Experience: The First Year of the P4P Contract
This article and related editorial evaluate the experience of family practitioners in the first year of the United Kingdom's National Health Service pay-for-performance contract. Introduced in 2004, this contract increases existing income according to performance with respect to 146 quality indicators covering clinical care for 10 chronic diseases, organization of care, and patient experience. The authors found English family practices attained high levels of achievement, but a small number of practices appear to have achieved high scores by excluding large numbers of patients through exception reporting. They conclude that more research is needed to determine whether these practices are excluding patients for sound clinical reasons or in order to increase income. T. Doran et al. (2006) Pay-for-Performance Programs in Family Practices in the United Kingdom New England Journal of Medicine 355, 375–384; A. M. Epstein (2006) Paying for Performance in the United States and Abroad New England Journal of Medicine 355, 406–408.
Older Adults
Colonoscopy: Does Medicare Coverage Decrease Disparities?
This article examined the effect of Medicare reimbursement of colonoscopy for average-risk beneficiaries on the rates of colorectal cancer screening among the elderly in the United States. The authors found this policy, effective July 2001, alleviated the screening disparity between non-Hispanic whites and blacks, but the gap between Hispanics and non-Hispanic whites has widened. Overall, fewer than half of the elderly are screened, even though Medicare now covers colonoscopy. Y. T. Shih et al. (2006) Does Medicare Coverage of Colonoscopy Reduce Racial/Ethnic Disparities in Cancer Screening Among the Elderly? Health Affairs 25, 1153–1162.