Quality Tools in Practice
Nurse-Led Intervention "Reasonably" Cost-Effective
A cost-effectiveness analysis, conducted alongside a randomized trial, was used to evaluate whether nurse-led management for heart failure patients is cost effective. The 12-month intervention, which included one face-to-face encounter with a nurse and regular telephone follow-up, resulted in higher costs and quality of life as compared with usual care. Based on cost-effectiveness acceptability curves, the authors conclude that the intervention was cost-effective for patients with less severe heart failure. P. L. Hebert, J. E. Sisk, J. J. Wang et al., Cost-Effectiveness of Nurse-Led Disease Management for Heart Failure in an Ethnically Diverse Urban Community, Annals of Internal Medicine, Oct. 21, 2008 149(8): 540–548.
Study: QI Collaborative Failed to Improve Outcomes
A longitudinal cluster randomized trial was used to assess the effects of a quality improvement collaborative—as the intervention—on preoperative antimicrobial prophylaxis. Hospitals were randomly assigned to the intervention group, which included participation in two in-person meetings led by experts, monthly teleconferences, and receipt of supplemental materials over a nine-month period. While noting the study's limitations, the authors found that the intervention did not improve patient's receipt of a properly timed antimicrobial prophylaxis dose, individual measures of antibiotic duration, use of appropriate drug, receipt of a single preoperative dose, or an all-or-none measure combing timing, duration, and selection. S. B. Kritchevsky, B. I. Braun, A. J. Bush et al., The Effect of a Quality Improvement Collaborative to Improve Antimicrobial Prophylaxis in Surgical Patients: A Randomized Trial, Annals of Internal Medicine, Oct. 7, 2008 149(7): 472–480.
Geisinger: Improving Quality and Outcomes While Lowering Costs
This paper focuses on care innovations established at Geisinger Health System, an integrated delivery system serving 2.5 million patients in central and northeastern Pennsylvania, including strategies such as patient-centered medical homes, chronic disease management, and bundled payment of acute-care episodes. The authors conclude that, even if not fully generalizable to nonintegrated health care organizations, Geisinger's experience can prove useful for health care leaders seeking to enhance value and offer potential insight for health system reforms. R. A. Paulus, K. Davis, and G. D. Steele, Continuous Innovation in Health Care: Implications of the Geisinger Experience, Health Affairs, Sept./Oct. 2008 27(5): 1235–1245.
Medical Home Adoption Among Large Groups Limited
The authors used data from the 2006–2007 National Study of Physician Organizations to examine the adoption of patient-centered medical home (PCMH) infrastructure components among large primary care and multispecialty medical groups. They found that the level of adoption of PCMH infrastructure components among large medical groups is, on average, low. However, PCMH infrastructure adoption varied considerably among these medical groups and was found to increase with very large organizational size and with ownership by a larger entity, such as a hospital or an HMO. They conclude that the model has a long way to go to achieve widespread implementation, and that its success depends on "whether it is able to go the distance and deliver a fundamentally different system of care that emphasizes primary care and results in improved overall health outcomes, decreased health disparities, and enhanced patient experience." D. R. Rittenhouse, L. P. Casalino, R. R. Gillies et al., Measuring the Medical Home Infrastructure in Large Medical Groups, Health Affairs, Sept./Oct. 2008 27(5): 1246–1258.
Measuring Performance
Process Measures Capture Unmeasured Information About Care
This study examined the association of hospital performance process measures with observed differences in risk-adjusted mortality rates and expected differences in risk-adjusted mortality rates. Using hospital performance data from Hospital Compare and risk-adjusted mortality rates from Medicare Part A claims in 2004, the authors compared observed differences in condition-specific hospital mortality rates based on hospital performance with expected differences in mortality from the clinical studies underlying the measures at 3,657 acute care U.S. hospitals. They found that performance measures reflect care processes that both improve care directly and are also markers of elements of health care quality that are otherwise unmeasured. M. Werner, E. T. Bradlow, and D. A. Asch, Does Hospital Performance on Process Measures Directly Measure High Quality Care or Is It a Marker of Unmeasured Care? Health Services Research, Oct. 2008 43(5p1): 1464–1484.
Measures Show Asthma Care for Children Lacking
This study used a modified Rand appropriateness method to identify nine appropriate, feasible, and reliable evidence-based clinical process measures for assessing the quality of inpatient asthma care for children. The authors then evaluated provider compliance with these measures, through a retrospective, manual chart review of data for 252 children, ages 2 to 17, admitted to a tertiary care children's hospital for asthma exacerbations in 2005. They found that provider compliance with these measures was highly variable, but generally low, highlighting the opportunities for improvement in the provision of asthma care for hospitalized children and the need for future studies to confirm these findings in other inpatient settings. F. L. Nkoy, B. A. Fassl, T. D. Simon et al., Quality of Care for Children Hospitalized With Asthma, Pediatrics, Nov. 2008 122(5): 1055–1063.
HEDIS Measures' Effect on Cardiovascular Disease and Diabetes
In this article, the authors analyze the effect that the systematic use of performance measures on a national scale has had on cardiovascular disease and diabetes outcomes, using the Archimedes model linked to the Third National Health and Nutrition Examination Survey. They found that the eight Health Care Employer Data and Information Set (HEDIS) measures for cardiovascular disease and diabetes "do a remarkable job in targeting opportunities for decreasing morbidity and mortality attributable to those conditions." At the time the HEDIS measures were introduced, almost half of U.S. adults stood to benefit from improved performance on at least one measure. Further, they found that "consistent implementation of the levels of performance achieved by the median health plan in 2005 would have prevented about two million myocardial infarctions between 1995 and 2005." D. M. Eddy, L. G. Pawlson, D. Schaaf et al., The Potential Effects of HEDIS Performance Measures on the Quality of Care, Health Affairs, Sept./Oct. 2008 27(5): 1429–1441.
Study Finds Associations Between Patient Satisfaction and Quality
The authors examined patients' perceptions of their care in the hospital setting, assessing the association between hospital characteristics assumed to enhance care and patients' satisfaction with their experience, as well as performance on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and its relationship to quality. They concluded that patients' experiences in U.S. hospitals offer insights into areas that need improvement. This was based on their findings that patients who received care in hospitals with a high ratio of nurses to patient-days reported somewhat better experiences than those who received care in hospitals with a lower ratio, and hospitals that performed well on the HCAHPS survey generally provided higher quality care than those that did not. A. K. Jha, E. J. Orav, J. Zheng et al., Patients' Perception of Hospital Care in the United States, New England Journal of Medicine, Oct. 30, 2008 359(18): 1921–1931.
Guidelines for Publishing QI Studies Revised
This article presents a revised version of guidelines for reporting quality improvement studies, called Standards for QUality Improvement Reporting Excellence (SQUIRE), created to stimulate the publication of high-caliber improvement studies. The authors describe the development process used to create the guidelines and revisions since their original publication in 2005. They also discuss SQUIRES's limitations and their plans to further develop, test, and disseminate the guidelines. F. Davidoff, P. Batalden, D. Stevens et al., Publication Guidelines for Improvement Studies in Health Care: Evolution of the SQUIRE Project, Annals of Internal Medicine, Nov. 4, 1008 149(9): 670–676.
Patient Safety
Study Finds Poor Patient Handoffs Cause Harm
Resident physicians in internal medicine and general surgery at Massachusetts General Hospital (MGH) were surveyed in 2006 about the quality and effects of handoffs during their most recent inpatient rotations. Among the 161 residents (response rate, 67.6 percent) who completed the survey, 59 percent reported that one or more patients had been harmed during their most recent clinical rotation because of problematic handoffs, and 12 percent reported that this harm had been major. The authors conclude that many best-practice recommendations for handoffs are not observed, although the extent to which such improvements would reduce patient harm is unknown. They also note that MGH recently launched a handoff-safety educational program, along with other interventions designed to improve the safety and effectiveness of handoffs. B. T. Kitch, J. B. Cooper, W. M. Zapol et al., Handoffs Causing Patient Harm: A Survey of Medical and Surgical House Staff, Joint Commission Journal on Quality and Patient Safety, Oct. 2008 34(10): 563–570.
Principles to Coordinate Inpatient and Outpatient Care Needed
Hospitalist use has shifted primary care physicians' primary responsibility for their patients, while hospitalized, to hospitalists who may be affiliated primarily with the hospital, a health plan, or other sponsors. The authors interviewed hospitalist and nonhospitalist respondents as part of the Community Tracking Study site visits to examine how the growing use of hospitalists has changed care delivery processes. They found that hospitalist programs have increased the burden of patient coordination and blurred accountability for the quality of postdischarge care, with arrangements where companies and multispecialty medical groups employ hospitalists more likely to establish routines for ensuring coordinated transitions. H. H. Pham, J. M. Grossman, G. Cohen et al., Hospitalists and Care Transitions: The Divorce of Inpatient and Outpatient Care, Health Affairs Sept./Oct. 2008 27(5): 1315–1327.
Quicklist of Common Pediatric Medications Reduces Errors
A retrospective comparison of orders from 840 randomly selected visits to a pediatric emergency department—half before and half after the introduction of a drug dosing support tool targeting common medications, called a quicklist—was used to determine the tool's impact on medication prescribing errors. Among the 724 medication orders generated by these visits, there were 156 medication prescribing errors. The authors found that the introduction of the quicklist led to a significant reduction in medication prescribing errors, from 24 to 13 errors per 100 visits and from 31 to 14 errors per 100 orders. They conclude that a "list with dosing support for commonly used pediatric medications may help adapt computerized physician order entry systems designed for adults to serve pediatric populations more effectively." B. E. Sard, K. E. Walsh, G. Doros et al., Retrospective Evaluation of a Computerized Physician Order Entry Adaptation to Prevent Prescribing Errors in a Pediatric Emergency Department, Pediatrics, Oct. 2008, 122(4): 782–787.
Nurse-Led Intervention "Reasonably" Cost-Effective
A cost-effectiveness analysis, conducted alongside a randomized trial, was used to evaluate whether nurse-led management for heart failure patients is cost effective. The 12-month intervention, which included one face-to-face encounter with a nurse and regular telephone follow-up, resulted in higher costs and quality of life as compared with usual care. Based on cost-effectiveness acceptability curves, the authors conclude that the intervention was cost-effective for patients with less severe heart failure. P. L. Hebert, J. E. Sisk, J. J. Wang et al., Cost-Effectiveness of Nurse-Led Disease Management for Heart Failure in an Ethnically Diverse Urban Community, Annals of Internal Medicine, Oct. 21, 2008 149(8): 540–548.
Study: QI Collaborative Failed to Improve Outcomes
A longitudinal cluster randomized trial was used to assess the effects of a quality improvement collaborative—as the intervention—on preoperative antimicrobial prophylaxis. Hospitals were randomly assigned to the intervention group, which included participation in two in-person meetings led by experts, monthly teleconferences, and receipt of supplemental materials over a nine-month period. While noting the study's limitations, the authors found that the intervention did not improve patient's receipt of a properly timed antimicrobial prophylaxis dose, individual measures of antibiotic duration, use of appropriate drug, receipt of a single preoperative dose, or an all-or-none measure combing timing, duration, and selection. S. B. Kritchevsky, B. I. Braun, A. J. Bush et al., The Effect of a Quality Improvement Collaborative to Improve Antimicrobial Prophylaxis in Surgical Patients: A Randomized Trial, Annals of Internal Medicine, Oct. 7, 2008 149(7): 472–480.
Geisinger: Improving Quality and Outcomes While Lowering Costs
This paper focuses on care innovations established at Geisinger Health System, an integrated delivery system serving 2.5 million patients in central and northeastern Pennsylvania, including strategies such as patient-centered medical homes, chronic disease management, and bundled payment of acute-care episodes. The authors conclude that, even if not fully generalizable to nonintegrated health care organizations, Geisinger's experience can prove useful for health care leaders seeking to enhance value and offer potential insight for health system reforms. R. A. Paulus, K. Davis, and G. D. Steele, Continuous Innovation in Health Care: Implications of the Geisinger Experience, Health Affairs, Sept./Oct. 2008 27(5): 1235–1245.
Medical Home Adoption Among Large Groups Limited
The authors used data from the 2006–2007 National Study of Physician Organizations to examine the adoption of patient-centered medical home (PCMH) infrastructure components among large primary care and multispecialty medical groups. They found that the level of adoption of PCMH infrastructure components among large medical groups is, on average, low. However, PCMH infrastructure adoption varied considerably among these medical groups and was found to increase with very large organizational size and with ownership by a larger entity, such as a hospital or an HMO. They conclude that the model has a long way to go to achieve widespread implementation, and that its success depends on "whether it is able to go the distance and deliver a fundamentally different system of care that emphasizes primary care and results in improved overall health outcomes, decreased health disparities, and enhanced patient experience." D. R. Rittenhouse, L. P. Casalino, R. R. Gillies et al., Measuring the Medical Home Infrastructure in Large Medical Groups, Health Affairs, Sept./Oct. 2008 27(5): 1246–1258.
Measuring Performance
Process Measures Capture Unmeasured Information About Care
This study examined the association of hospital performance process measures with observed differences in risk-adjusted mortality rates and expected differences in risk-adjusted mortality rates. Using hospital performance data from Hospital Compare and risk-adjusted mortality rates from Medicare Part A claims in 2004, the authors compared observed differences in condition-specific hospital mortality rates based on hospital performance with expected differences in mortality from the clinical studies underlying the measures at 3,657 acute care U.S. hospitals. They found that performance measures reflect care processes that both improve care directly and are also markers of elements of health care quality that are otherwise unmeasured. M. Werner, E. T. Bradlow, and D. A. Asch, Does Hospital Performance on Process Measures Directly Measure High Quality Care or Is It a Marker of Unmeasured Care? Health Services Research, Oct. 2008 43(5p1): 1464–1484.
Measures Show Asthma Care for Children Lacking
This study used a modified Rand appropriateness method to identify nine appropriate, feasible, and reliable evidence-based clinical process measures for assessing the quality of inpatient asthma care for children. The authors then evaluated provider compliance with these measures, through a retrospective, manual chart review of data for 252 children, ages 2 to 17, admitted to a tertiary care children's hospital for asthma exacerbations in 2005. They found that provider compliance with these measures was highly variable, but generally low, highlighting the opportunities for improvement in the provision of asthma care for hospitalized children and the need for future studies to confirm these findings in other inpatient settings. F. L. Nkoy, B. A. Fassl, T. D. Simon et al., Quality of Care for Children Hospitalized With Asthma, Pediatrics, Nov. 2008 122(5): 1055–1063.
HEDIS Measures' Effect on Cardiovascular Disease and Diabetes
In this article, the authors analyze the effect that the systematic use of performance measures on a national scale has had on cardiovascular disease and diabetes outcomes, using the Archimedes model linked to the Third National Health and Nutrition Examination Survey. They found that the eight Health Care Employer Data and Information Set (HEDIS) measures for cardiovascular disease and diabetes "do a remarkable job in targeting opportunities for decreasing morbidity and mortality attributable to those conditions." At the time the HEDIS measures were introduced, almost half of U.S. adults stood to benefit from improved performance on at least one measure. Further, they found that "consistent implementation of the levels of performance achieved by the median health plan in 2005 would have prevented about two million myocardial infarctions between 1995 and 2005." D. M. Eddy, L. G. Pawlson, D. Schaaf et al., The Potential Effects of HEDIS Performance Measures on the Quality of Care, Health Affairs, Sept./Oct. 2008 27(5): 1429–1441.
Study Finds Associations Between Patient Satisfaction and Quality
The authors examined patients' perceptions of their care in the hospital setting, assessing the association between hospital characteristics assumed to enhance care and patients' satisfaction with their experience, as well as performance on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and its relationship to quality. They concluded that patients' experiences in U.S. hospitals offer insights into areas that need improvement. This was based on their findings that patients who received care in hospitals with a high ratio of nurses to patient-days reported somewhat better experiences than those who received care in hospitals with a lower ratio, and hospitals that performed well on the HCAHPS survey generally provided higher quality care than those that did not. A. K. Jha, E. J. Orav, J. Zheng et al., Patients' Perception of Hospital Care in the United States, New England Journal of Medicine, Oct. 30, 2008 359(18): 1921–1931.
Guidelines for Publishing QI Studies Revised
This article presents a revised version of guidelines for reporting quality improvement studies, called Standards for QUality Improvement Reporting Excellence (SQUIRE), created to stimulate the publication of high-caliber improvement studies. The authors describe the development process used to create the guidelines and revisions since their original publication in 2005. They also discuss SQUIRES's limitations and their plans to further develop, test, and disseminate the guidelines. F. Davidoff, P. Batalden, D. Stevens et al., Publication Guidelines for Improvement Studies in Health Care: Evolution of the SQUIRE Project, Annals of Internal Medicine, Nov. 4, 1008 149(9): 670–676.
Patient Safety
Study Finds Poor Patient Handoffs Cause Harm
Resident physicians in internal medicine and general surgery at Massachusetts General Hospital (MGH) were surveyed in 2006 about the quality and effects of handoffs during their most recent inpatient rotations. Among the 161 residents (response rate, 67.6 percent) who completed the survey, 59 percent reported that one or more patients had been harmed during their most recent clinical rotation because of problematic handoffs, and 12 percent reported that this harm had been major. The authors conclude that many best-practice recommendations for handoffs are not observed, although the extent to which such improvements would reduce patient harm is unknown. They also note that MGH recently launched a handoff-safety educational program, along with other interventions designed to improve the safety and effectiveness of handoffs. B. T. Kitch, J. B. Cooper, W. M. Zapol et al., Handoffs Causing Patient Harm: A Survey of Medical and Surgical House Staff, Joint Commission Journal on Quality and Patient Safety, Oct. 2008 34(10): 563–570.
Principles to Coordinate Inpatient and Outpatient Care Needed
Hospitalist use has shifted primary care physicians' primary responsibility for their patients, while hospitalized, to hospitalists who may be affiliated primarily with the hospital, a health plan, or other sponsors. The authors interviewed hospitalist and nonhospitalist respondents as part of the Community Tracking Study site visits to examine how the growing use of hospitalists has changed care delivery processes. They found that hospitalist programs have increased the burden of patient coordination and blurred accountability for the quality of postdischarge care, with arrangements where companies and multispecialty medical groups employ hospitalists more likely to establish routines for ensuring coordinated transitions. H. H. Pham, J. M. Grossman, G. Cohen et al., Hospitalists and Care Transitions: The Divorce of Inpatient and Outpatient Care, Health Affairs Sept./Oct. 2008 27(5): 1315–1327.
Quicklist of Common Pediatric Medications Reduces Errors
A retrospective comparison of orders from 840 randomly selected visits to a pediatric emergency department—half before and half after the introduction of a drug dosing support tool targeting common medications, called a quicklist—was used to determine the tool's impact on medication prescribing errors. Among the 724 medication orders generated by these visits, there were 156 medication prescribing errors. The authors found that the introduction of the quicklist led to a significant reduction in medication prescribing errors, from 24 to 13 errors per 100 visits and from 31 to 14 errors per 100 orders. They conclude that a "list with dosing support for commonly used pediatric medications may help adapt computerized physician order entry systems designed for adults to serve pediatric populations more effectively." B. E. Sard, K. E. Walsh, G. Doros et al., Retrospective Evaluation of a Computerized Physician Order Entry Adaptation to Prevent Prescribing Errors in a Pediatric Emergency Department, Pediatrics, Oct. 2008, 122(4): 782–787.