Health Care System Performance
U.S. Primary Care Lags Behind Other Nations
The Commonwealth Fund 2006 International Health Policy Survey focused on systems and policies to enhance the effectiveness and efficiency of primary care practice in the U.S. as well as Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom. It found that U.S. primary care practices are less likely than those in other countries to offer patients access to care outside regular office hours or have systems that alert doctors to potentially harmful drug interactions. And, despite growing U.S. interest in financial incentives to improve performance, U.S. primary care doctors are among the least likely to receive such incentives. The authors conclude that national policies are needed to strengthen and support primary care. C. Schoen et al. (2006) On the Front Lines of Care: Primary Care Doctors' Office Systems, Experiences, and Views in Seven Countries Health Affairs Web Exclusive, Nov. 2, 2006: w555–w571.
Pharmacologic Care: Room for Improvement
A random sample of U.S. adults was interviewed by telephone and their medical records abstracted to evaluate four prescribing processes: appropriate medication prescribing (underuse), avoidance of inappropriate medications (overuse), medication monitoring, and medication education and documentation. Participants (3,457 total) received 61.9 percent of recommended pharmacologic care overall, with the lowest performance in education and documentation (46.2%). Performance was higher in medication monitoring (54.7%) and underuse of appropriate medications (62.6%), and was best for avoiding inappropriate medications (83.5%). The authors conclude that strategies to measure and improve pharmacologic care quality should be developed to address identified deficits. W. H. Shrank et al. (2006) The Quality of Pharmacologic Care for Adults in the United States. Medical Care 44, 936–945.
Error Identification and Prevention
Common Diagnostic Errors Identified in Malpractice Claims
A retrospective review of 307 closed malpractice claims, in which patients alleged a missed or delayed diagnosis in the ambulatory setting, found 181 claims (59%) involved diagnostic errors that harmed patients. Of these diagnostic errors, 59 percent were associated with serious harm and 30 percent resulted in death. The authors conclude that awareness of the multiple individual and systems factors that lead to diagnostic errors might help to identify and prioritize strategies that prevent their occurrence. T. K. Gandhi et al. (2006) Missed and Delayed Diagnoses in the Ambulatory Setting: A Study of Closed Malpractice Claims. Annals of Internal Medicine 145, 488–496.
Bar Code Technology Decreases Drug Errors
A before-and-after study at an academic medical center pharmacy used direct observation to assess three configurations of a bar code–assisted dispensing system. The configurations varied in the number of times doses were scanned. Study authors observed 115,164 dispensed medication doses prior to implementing the bar code system and 253,984 afterward, and found the rates of target potential adverse drug events (ADEs) and all potential ADEs decreased by 74 percent and 63 percent, respectively. Further, based on comparisons between the three configurations, they concluded that bar code systems should be configured to scan every dose during the dispensing process. E. G. Poon et al. (2006) Medication Dispensing Errors and Potential Adverse Drug Events Before and After Implementing Bar Code Technology in the Pharmacy. Annals of Internal Medicine 145, 426–434.
Outpatient Drug Errors Linked to Morbidity
Active surveillance through the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance project identified 21,298 adverse drug events (ADEs) between Jan. 1, 2004, and Dec. 31, 2005. These ADEs accounted for 2.5 percent of estimated emergency department visits for all unintentional injuries and 6.7 percent of those leading to hospitalization. Also, they accounted for 0.6 percent of estimated emergency department visits for all causes and were found to be more common among individuals aged 65 years or older. The authors conclude that ongoing, population-based surveillance can be used to monitor ADEs and focus prevention strategies. D. S. Budnitz et al. (2006) National Surveillance of Emergency Department Visits for Outpatient Adverse Drug Events. Journal of the American Medical Association 296, 1858–1866.
Quality Tools in Practice
100,000 Lives?
This article reviews the Institute for Healthcare Improvement (IHI) campaign to save 100,000 lives, which established and promoted a set of achievable goals for American hospitals. The authors, while acknowledging its success in catalyzing efforts to improve safety and quality, conclude that "the promotion of rapid response teams as a national standard is problematic, and methodologic concerns regarding the 'lives saved' calculations make it difficult to interpret the campaign's true accomplishments." This review is followed by a response from the IHI. R. M. Wachter and P. J. Pronovost (2006) The 100,000 Lives Campaign: A Scientific and Policy Review. Joint Commission Journal on Quality and Patient Safety 32, 621–627; and D. M. Berwick et al. (2006) IHI Replies to 'The 100,000 Lives Campaign: A Scientific and Policy Review.' Joint Commission Journal on Quality and Patient Safety 32, 628–633.
Guidelines Improve Pneumonia Outcomes
A retrospective cohort study of all adult community-acquired pneumonia patients managed at five community hospitals (from Nov. 1, 1999, to April 30, 2000) found 57 percent (357 of 631 patients) received guideline-concordant empiric antibiotic therapy. Further, this therapy is associated with improved in-hospital survival and shorter time to clinical stability, time to switch therapy, and length of hospital stay. C. R. Frei et al. (2006) Impact of Guideline-Concordant Empiric Antibiotic Therapy in Community-Acquired Pneumonia. American Journal of Medicine 119, 865–871.
Pharmacist Counseling Improves Compliance, Reduces Mortality
A two-year, randomized controlled trial investigated the effects of periodic telephone counseling by a pharmacist among patients receiving five or more drugs for chronic disease at a hospital medical clinic. After adjustment for confounders, telephone counseling was found to improve patient compliance with polypharmacy and to be associated with a 41 percent reduction in the risk of death. J. Y. F. Wu et al. (2006) Effectiveness of Telephone Counselling by a Pharmacist in Reducing Mortality in Patients Receiving Polypharmacy: Randomised Controlled Trial. BMJ 333, 522.
Clinician Prompting Improves Pediatric Asthma Care
A randomized controlled trial at two inner-city pediatric practices in Rochester, N.Y., evaluated the effect of clinician prompting regarding a child's symptom severity and guideline recommendations at the time of an office visit on the quality of preventive asthma care. The authors found that visits for children in the clinician-prompting group were more likely to include delivery of an action plan (50% vs. 24%), discussions regarding asthma (87% vs. 76%), and recommendations for an asthma follow-up visit (54% vs. 37%). In a regression model, this group had threefold greater odds of receiving any preventive action. J. S. Halterman et al. (2006) Improved Preventive Care for Asthma: A Randomized Trial of Clinician Prompting in Pediatric Offices. Archives of Pediatric & Adolescent Medicine 160, 1018–1025.
"Open Access" Scheduling Improves Access to Well-Child Care
This study compared two methods of "open access" scheduling of well-child care visits—future appointments made when leaving a well-child visit and same-day appointments made upon request—at one community health center pediatric clinic. During the study period, from Aug. 1, 2003, to Jan. 31, 2004, missed appointment rates decreased from 21 percent at baseline to 14 percent among the future-visit group and 9 percent among the same-day group. On-time immunizations increased from 59 percent at baseline to 74 percent in both the future-visit group and same-day group. The authors conclude that open access scheduling decreases missed appointments for well-child visits and appears to increase on-time immunizations. M. E. O'Connor et al. (2006) Effect of Open Access Scheduling on Missed Appointments, Immunizations, and Continuity of Care for Infant Well-Child Care Visits. Archives of Pediatric and Adolescent Medicine 160, 889–893.
Information Technology
Survey: Few Physicians Using Basic IT
A national survey of U.S. physicians, both primary care and specialist, assessed their use of information technology that is not related to electronic health records. It found "frequent" use was highest for computerized decision support (40.8%) and online professional journal access (39.0%), and lowest for e-mail communication with patients (3.4%). However, 10 percent of physicians "never used any of the five IT tools," which also included e-mail communication with other clinicians and online access to continuing medicine education. The authors conclude that, in early 2004, most physicians were not regularly using basic IT tools in their clinical practice. R. W. Grant et al. (2006) Prevalence of Basic Information Technology Use by U.S. Physicians. Journal of General Internal Medicine 21, 1150–1155.
Pay-for-Performance
P4P Common in HMO Contracts
A survey of 252 health maintenance organizations (HMOs) drawn from 41 metropolitan areas across the nation (response rate 96%) found that more than half of them use pay-for-performance in their provider contracts. Among the 126 health plans with pay-for-performance programs, representing more than 80 percent of persons enrolled, nearly 90 percent have programs for physicians and 38 percent have programs for hospitals. The authors conclude that it will be important to leverage this early experience as the Centers for Medicare and Medicaid Services moves closer to adopting pay-for-performance mechanisms in Medicare. M. B. Rosenthal et al. (2006) Pay for Performance in Commercial HMOs. New England Journal of Medicine 355, 1895–1902.
U.S. Primary Care Lags Behind Other Nations
The Commonwealth Fund 2006 International Health Policy Survey focused on systems and policies to enhance the effectiveness and efficiency of primary care practice in the U.S. as well as Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom. It found that U.S. primary care practices are less likely than those in other countries to offer patients access to care outside regular office hours or have systems that alert doctors to potentially harmful drug interactions. And, despite growing U.S. interest in financial incentives to improve performance, U.S. primary care doctors are among the least likely to receive such incentives. The authors conclude that national policies are needed to strengthen and support primary care. C. Schoen et al. (2006) On the Front Lines of Care: Primary Care Doctors' Office Systems, Experiences, and Views in Seven Countries Health Affairs Web Exclusive, Nov. 2, 2006: w555–w571.
Pharmacologic Care: Room for Improvement
A random sample of U.S. adults was interviewed by telephone and their medical records abstracted to evaluate four prescribing processes: appropriate medication prescribing (underuse), avoidance of inappropriate medications (overuse), medication monitoring, and medication education and documentation. Participants (3,457 total) received 61.9 percent of recommended pharmacologic care overall, with the lowest performance in education and documentation (46.2%). Performance was higher in medication monitoring (54.7%) and underuse of appropriate medications (62.6%), and was best for avoiding inappropriate medications (83.5%). The authors conclude that strategies to measure and improve pharmacologic care quality should be developed to address identified deficits. W. H. Shrank et al. (2006) The Quality of Pharmacologic Care for Adults in the United States. Medical Care 44, 936–945.
Error Identification and Prevention
Common Diagnostic Errors Identified in Malpractice Claims
A retrospective review of 307 closed malpractice claims, in which patients alleged a missed or delayed diagnosis in the ambulatory setting, found 181 claims (59%) involved diagnostic errors that harmed patients. Of these diagnostic errors, 59 percent were associated with serious harm and 30 percent resulted in death. The authors conclude that awareness of the multiple individual and systems factors that lead to diagnostic errors might help to identify and prioritize strategies that prevent their occurrence. T. K. Gandhi et al. (2006) Missed and Delayed Diagnoses in the Ambulatory Setting: A Study of Closed Malpractice Claims. Annals of Internal Medicine 145, 488–496.
Bar Code Technology Decreases Drug Errors
A before-and-after study at an academic medical center pharmacy used direct observation to assess three configurations of a bar code–assisted dispensing system. The configurations varied in the number of times doses were scanned. Study authors observed 115,164 dispensed medication doses prior to implementing the bar code system and 253,984 afterward, and found the rates of target potential adverse drug events (ADEs) and all potential ADEs decreased by 74 percent and 63 percent, respectively. Further, based on comparisons between the three configurations, they concluded that bar code systems should be configured to scan every dose during the dispensing process. E. G. Poon et al. (2006) Medication Dispensing Errors and Potential Adverse Drug Events Before and After Implementing Bar Code Technology in the Pharmacy. Annals of Internal Medicine 145, 426–434.
Outpatient Drug Errors Linked to Morbidity
Active surveillance through the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance project identified 21,298 adverse drug events (ADEs) between Jan. 1, 2004, and Dec. 31, 2005. These ADEs accounted for 2.5 percent of estimated emergency department visits for all unintentional injuries and 6.7 percent of those leading to hospitalization. Also, they accounted for 0.6 percent of estimated emergency department visits for all causes and were found to be more common among individuals aged 65 years or older. The authors conclude that ongoing, population-based surveillance can be used to monitor ADEs and focus prevention strategies. D. S. Budnitz et al. (2006) National Surveillance of Emergency Department Visits for Outpatient Adverse Drug Events. Journal of the American Medical Association 296, 1858–1866.
Quality Tools in Practice
100,000 Lives?
This article reviews the Institute for Healthcare Improvement (IHI) campaign to save 100,000 lives, which established and promoted a set of achievable goals for American hospitals. The authors, while acknowledging its success in catalyzing efforts to improve safety and quality, conclude that "the promotion of rapid response teams as a national standard is problematic, and methodologic concerns regarding the 'lives saved' calculations make it difficult to interpret the campaign's true accomplishments." This review is followed by a response from the IHI. R. M. Wachter and P. J. Pronovost (2006) The 100,000 Lives Campaign: A Scientific and Policy Review. Joint Commission Journal on Quality and Patient Safety 32, 621–627; and D. M. Berwick et al. (2006) IHI Replies to 'The 100,000 Lives Campaign: A Scientific and Policy Review.' Joint Commission Journal on Quality and Patient Safety 32, 628–633.
Guidelines Improve Pneumonia Outcomes
A retrospective cohort study of all adult community-acquired pneumonia patients managed at five community hospitals (from Nov. 1, 1999, to April 30, 2000) found 57 percent (357 of 631 patients) received guideline-concordant empiric antibiotic therapy. Further, this therapy is associated with improved in-hospital survival and shorter time to clinical stability, time to switch therapy, and length of hospital stay. C. R. Frei et al. (2006) Impact of Guideline-Concordant Empiric Antibiotic Therapy in Community-Acquired Pneumonia. American Journal of Medicine 119, 865–871.
Pharmacist Counseling Improves Compliance, Reduces Mortality
A two-year, randomized controlled trial investigated the effects of periodic telephone counseling by a pharmacist among patients receiving five or more drugs for chronic disease at a hospital medical clinic. After adjustment for confounders, telephone counseling was found to improve patient compliance with polypharmacy and to be associated with a 41 percent reduction in the risk of death. J. Y. F. Wu et al. (2006) Effectiveness of Telephone Counselling by a Pharmacist in Reducing Mortality in Patients Receiving Polypharmacy: Randomised Controlled Trial. BMJ 333, 522.
Clinician Prompting Improves Pediatric Asthma Care
A randomized controlled trial at two inner-city pediatric practices in Rochester, N.Y., evaluated the effect of clinician prompting regarding a child's symptom severity and guideline recommendations at the time of an office visit on the quality of preventive asthma care. The authors found that visits for children in the clinician-prompting group were more likely to include delivery of an action plan (50% vs. 24%), discussions regarding asthma (87% vs. 76%), and recommendations for an asthma follow-up visit (54% vs. 37%). In a regression model, this group had threefold greater odds of receiving any preventive action. J. S. Halterman et al. (2006) Improved Preventive Care for Asthma: A Randomized Trial of Clinician Prompting in Pediatric Offices. Archives of Pediatric & Adolescent Medicine 160, 1018–1025.
"Open Access" Scheduling Improves Access to Well-Child Care
This study compared two methods of "open access" scheduling of well-child care visits—future appointments made when leaving a well-child visit and same-day appointments made upon request—at one community health center pediatric clinic. During the study period, from Aug. 1, 2003, to Jan. 31, 2004, missed appointment rates decreased from 21 percent at baseline to 14 percent among the future-visit group and 9 percent among the same-day group. On-time immunizations increased from 59 percent at baseline to 74 percent in both the future-visit group and same-day group. The authors conclude that open access scheduling decreases missed appointments for well-child visits and appears to increase on-time immunizations. M. E. O'Connor et al. (2006) Effect of Open Access Scheduling on Missed Appointments, Immunizations, and Continuity of Care for Infant Well-Child Care Visits. Archives of Pediatric and Adolescent Medicine 160, 889–893.
Information Technology
Survey: Few Physicians Using Basic IT
A national survey of U.S. physicians, both primary care and specialist, assessed their use of information technology that is not related to electronic health records. It found "frequent" use was highest for computerized decision support (40.8%) and online professional journal access (39.0%), and lowest for e-mail communication with patients (3.4%). However, 10 percent of physicians "never used any of the five IT tools," which also included e-mail communication with other clinicians and online access to continuing medicine education. The authors conclude that, in early 2004, most physicians were not regularly using basic IT tools in their clinical practice. R. W. Grant et al. (2006) Prevalence of Basic Information Technology Use by U.S. Physicians. Journal of General Internal Medicine 21, 1150–1155.
Pay-for-Performance
P4P Common in HMO Contracts
A survey of 252 health maintenance organizations (HMOs) drawn from 41 metropolitan areas across the nation (response rate 96%) found that more than half of them use pay-for-performance in their provider contracts. Among the 126 health plans with pay-for-performance programs, representing more than 80 percent of persons enrolled, nearly 90 percent have programs for physicians and 38 percent have programs for hospitals. The authors conclude that it will be important to leverage this early experience as the Centers for Medicare and Medicaid Services moves closer to adopting pay-for-performance mechanisms in Medicare. M. B. Rosenthal et al. (2006) Pay for Performance in Commercial HMOs. New England Journal of Medicine 355, 1895–1902.