Health Care System Performance
Improving Systems of Care
To improve safety in the U.S. health care system, improvement should be approached from a systems point of view, the authors write in this commentary. This includes thinking broadly about changes to the interorganizational and interunit processes through which patients receive care. Specifically, they recommend the "implementation of systems thinking throughout the organization and across organizations, the development and empowerment of teams, a foundation of information that is used for accountability and learning, and shared responsibility for system improvement." S. M. Shortell and S. J. Singer (2008) Improving Patient Safety by Taking Systems Seriously. Journal of the American Medical Association 299, 445–447.
Patient Safety
Post-Discharge Adverse Events
A literature search of U.S. and Canadian articles published from 1966 through May 2007 identified two studies that examined the incidence rate of all types of postdischarge adverse events. These studies suggest that about one of five internal medicine patients discharged home from major North American teaching hospitals suffered an adverse event. Patient safety experts, the authors conclude, should recognize postdischarge care as an important area for improvement, particularly: transitional care, information transfer, medication reconciliation, test result follow-up, and the identification of patients who suffer from adverse events. D. Tsilimingras and D. W. Bates (2008) Addressing Postdischarge Adverse Events: A Neglected Area. Joint Commission Journal on Quality and Patient Safety 34, 85–97.
Pediatrics Resident Depression Affects Error Rate
A prospective cohort study was used to assess the prevalence of depression and burnout among pediatrics residents at three U.S children's hospitals and to determine whether a relationship exists between these disorders and medication errors. It found 24 of the 123 participating residents, or 20 percent, met the criteria for depression and 92, or 74 percent, met the criteria for burnout. Of the 45 errors identified, depressed residents made 6.2 times as many medication errors per resident month as residents who were not depressed. However, the rates did not vary between burnt out and non–burnt out residents. A. M. Fahrenkopf et al. (2008) Rates of Medication Errors Among Depressed and Burnt Out Residents: Prospective Cohort Study. British Medical Journal 336, 488–491.
Quality Tools in Practice
Is Root Cause Analysis Effective?
In the last decade, root cause analysis has become the central method the health care system uses to learn from mistakes and to mitigate future hazards. This process answers three basic questions: what happened, why did it happen, and what can be done to prevent it from happening again? The authors argue that a fourth question is necessary in medicine: has the risk of recurrence actually been reduced? They recommend evaluating root cause analysis for its effectiveness, working to develop consistent mechanisms for its implementation, and tracking the outcomes of these interventions—perhaps through a national oversight body. A. W. Wu et al. (2008) Effectiveness and Efficiency of Root Cause Analysis in Medicine. Journal of the American Medical Association 299, 685–687.
CTM Supported for Diverse Populations
A cross-sectional study with purposive sampling of traditionally underserved populations was used to examine the performance of the Care Transitions Measure (CTM) and introduce a three-item CTM. The analyses supported the use of the 15-item CTM among diverse populations, and regression analyses found that the three-item CTM explained 88 percent of the variance in the 15-item CTM score. These findings, the authors conclude, support the use of the CTM, which has been endorsed by the National Quality Forum, for use in national reporting efforts. Further, they suggest the three-item CTM approximates the 15-item measure and may be attractive to practices that want to assess quality in this area while minimizing time and cost burdens. C. Parry et al. (2008) Assessing the Quality of Transitional Care: Further Applications of the Care Transitions Measure. Medical Care 46, 317–322.
CPOE Reduces Prescribing Errors
A literature review (of articles published in English from 1990 through December 2005) identified 252 studies that examine the association between the computerization of physician orders and prescribing medication errors. The use of computerized orders was associated with a 66 percent reduction in total prescribing errors in adults and a positive tendency in children. More specifically, 80 percent of the studies reported that computerized orders resulted in a significant reduction in total prescribing errors, 43 percent in dosing errors, and 37.5 percent in adverse drug events, as compared with handwritten orders. T. A. Shamliyan et al. (2008) Just What the Doctor Ordered. Review of the Evidence of the Impact of Computerized Physician Order Entry System on Medication Errors. Health Services Research 43, 32–53.
Evaluating Heart Failure Interventions
A multicenter, randomized controlled trial, called the Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH), enrolled 1,023 patients after hospitalization due to heart failure. Two interventions, basic or intensive support by a nurse specializing in heart failure management, were compared with standard care, consisting of follow-up with a cardiologist. Though neither intervention was found to reduce the combined end points of death or hospitalization, the authors found a "nonsignificant, potentially relevant reduction in mortality, accompanied by a slight increase in the number of short hospitalizations in both intervention groups." T. Jaarsma et al. (2008) Effect of Moderate or Intensive Disease Management Program on Outcome in Patients With Heart Failure: Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH). Archives of Internal Medicine 168, 316–324.
Public Reporting's Effect on Quality
The authors reviewed 45 peer-reviewed articles (published since 1986) assessing the effect of publicly releasing performance data on health care quality. They found that the heterogeneity of the available studies made comparisons challenging, with little evidence available on individual providers and practices or rigorous evaluation of many major public reporting systems. Thus, despite evidence that public reporting stimulates quality improvement activity at the hospital level, its impact on effectiveness, safety, and patient-centeredness remains unclear. C. H. Fung et al. (2008) Systematic Review: The Evidence That Publishing Patient Care Performance Data Improves Quality of Care. Annals of Internal Medicine 148, 111–123.
Ethics of Quality Improvement
OHRP's Conclusion Regarding Consent Erroneous
The authors review the Office for Human Research Protections (OHRP) suspension of a quality improvement research project, aimed at reducing catheter-related infections in the intensive care unit at 67 Michigan hospitals, from both ethical and regulatory perspectives. They conclude that the institutional review board "should have undertaken a full or expedited review of the study protocol instead of deeming it exempt." They also believe that OHRP was incorrect in its conclusion that informed consent was necessary for the improvement project to continue. F. G. Miller and E. J. Emanuel (2008) Quality Improvement Research and Informed Consent. New England Journal of Medicine 358, 765–767.
QI, Not Human Subjects Research
This perspective reviews the Office for Human Research Protections' decision to suspend an intervention that aimed to reduce infections in the intensive care units of 67 Michigan hospitals. The author writes: "In my view, the project was a combination of quality improvement and research on organizations, not human subjects research, and the regulations did not apply." She concludes that the regulations need to be modified or reinterpreted to "protect people from risky research without discouraging low-risk, data-guided activities designed to make our health care system work better." M. A. Baily (2008) Harming Through Protection? New England Journal of Medicine 358, 768–769.
Financial Incentives for Quality
Limiting Payment for Preventable Errors
Medicare plans to withhold additional payments for "serious preventable events," beginning in 2009. The authors review this new policy and conclude that it "seems reasonable if evidence demonstrates that most of the adverse events can be prevented by widespread adoption of achievable practices, the events can be measured accurately, the events resulted in clinically significant patient harm, and [present on admission] determination is feasible." However, close monitoring of this new Medicare policy will be necessary, they say, as it will likely lead to "instances of unfairness, gaming, and unforeseen consequences." R. M. Wachter et al. (2008) Medicare's Decision to Withhold Payment for Hospital Errors: The Devil Is in the Details. Joint Commission Journal on Quality and Patient Safety 34, 116–123.
Reduced Copayments Improve Medication Adherence
A large employer's value-based insurance initiative, designed to improve adherence to recommended treatment regimens, was found to reduce copayments for five chronic medication classes in the context of a disease management program. Medication adherence increased for four of five medication classes, reducing nonadherence by 7 to14 percent, as compared with a control employer using the same disease management program. The authors conclude that copayment reductions for highly valued services have the potential to increase medication adherence above that achieved by existing disease management programs. M. E. Chernew et al. (2008) Impact of Decreasing Copayments on Medication Adherence Within a Disease Management Environment. Health Affairs 27, 10–112.
Improving Systems of Care
To improve safety in the U.S. health care system, improvement should be approached from a systems point of view, the authors write in this commentary. This includes thinking broadly about changes to the interorganizational and interunit processes through which patients receive care. Specifically, they recommend the "implementation of systems thinking throughout the organization and across organizations, the development and empowerment of teams, a foundation of information that is used for accountability and learning, and shared responsibility for system improvement." S. M. Shortell and S. J. Singer (2008) Improving Patient Safety by Taking Systems Seriously. Journal of the American Medical Association 299, 445–447.
Patient Safety
Post-Discharge Adverse Events
A literature search of U.S. and Canadian articles published from 1966 through May 2007 identified two studies that examined the incidence rate of all types of postdischarge adverse events. These studies suggest that about one of five internal medicine patients discharged home from major North American teaching hospitals suffered an adverse event. Patient safety experts, the authors conclude, should recognize postdischarge care as an important area for improvement, particularly: transitional care, information transfer, medication reconciliation, test result follow-up, and the identification of patients who suffer from adverse events. D. Tsilimingras and D. W. Bates (2008) Addressing Postdischarge Adverse Events: A Neglected Area. Joint Commission Journal on Quality and Patient Safety 34, 85–97.
Pediatrics Resident Depression Affects Error Rate
A prospective cohort study was used to assess the prevalence of depression and burnout among pediatrics residents at three U.S children's hospitals and to determine whether a relationship exists between these disorders and medication errors. It found 24 of the 123 participating residents, or 20 percent, met the criteria for depression and 92, or 74 percent, met the criteria for burnout. Of the 45 errors identified, depressed residents made 6.2 times as many medication errors per resident month as residents who were not depressed. However, the rates did not vary between burnt out and non–burnt out residents. A. M. Fahrenkopf et al. (2008) Rates of Medication Errors Among Depressed and Burnt Out Residents: Prospective Cohort Study. British Medical Journal 336, 488–491.
Quality Tools in Practice
Is Root Cause Analysis Effective?
In the last decade, root cause analysis has become the central method the health care system uses to learn from mistakes and to mitigate future hazards. This process answers three basic questions: what happened, why did it happen, and what can be done to prevent it from happening again? The authors argue that a fourth question is necessary in medicine: has the risk of recurrence actually been reduced? They recommend evaluating root cause analysis for its effectiveness, working to develop consistent mechanisms for its implementation, and tracking the outcomes of these interventions—perhaps through a national oversight body. A. W. Wu et al. (2008) Effectiveness and Efficiency of Root Cause Analysis in Medicine. Journal of the American Medical Association 299, 685–687.
CTM Supported for Diverse Populations
A cross-sectional study with purposive sampling of traditionally underserved populations was used to examine the performance of the Care Transitions Measure (CTM) and introduce a three-item CTM. The analyses supported the use of the 15-item CTM among diverse populations, and regression analyses found that the three-item CTM explained 88 percent of the variance in the 15-item CTM score. These findings, the authors conclude, support the use of the CTM, which has been endorsed by the National Quality Forum, for use in national reporting efforts. Further, they suggest the three-item CTM approximates the 15-item measure and may be attractive to practices that want to assess quality in this area while minimizing time and cost burdens. C. Parry et al. (2008) Assessing the Quality of Transitional Care: Further Applications of the Care Transitions Measure. Medical Care 46, 317–322.
CPOE Reduces Prescribing Errors
A literature review (of articles published in English from 1990 through December 2005) identified 252 studies that examine the association between the computerization of physician orders and prescribing medication errors. The use of computerized orders was associated with a 66 percent reduction in total prescribing errors in adults and a positive tendency in children. More specifically, 80 percent of the studies reported that computerized orders resulted in a significant reduction in total prescribing errors, 43 percent in dosing errors, and 37.5 percent in adverse drug events, as compared with handwritten orders. T. A. Shamliyan et al. (2008) Just What the Doctor Ordered. Review of the Evidence of the Impact of Computerized Physician Order Entry System on Medication Errors. Health Services Research 43, 32–53.
Evaluating Heart Failure Interventions
A multicenter, randomized controlled trial, called the Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH), enrolled 1,023 patients after hospitalization due to heart failure. Two interventions, basic or intensive support by a nurse specializing in heart failure management, were compared with standard care, consisting of follow-up with a cardiologist. Though neither intervention was found to reduce the combined end points of death or hospitalization, the authors found a "nonsignificant, potentially relevant reduction in mortality, accompanied by a slight increase in the number of short hospitalizations in both intervention groups." T. Jaarsma et al. (2008) Effect of Moderate or Intensive Disease Management Program on Outcome in Patients With Heart Failure: Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH). Archives of Internal Medicine 168, 316–324.
Public Reporting's Effect on Quality
The authors reviewed 45 peer-reviewed articles (published since 1986) assessing the effect of publicly releasing performance data on health care quality. They found that the heterogeneity of the available studies made comparisons challenging, with little evidence available on individual providers and practices or rigorous evaluation of many major public reporting systems. Thus, despite evidence that public reporting stimulates quality improvement activity at the hospital level, its impact on effectiveness, safety, and patient-centeredness remains unclear. C. H. Fung et al. (2008) Systematic Review: The Evidence That Publishing Patient Care Performance Data Improves Quality of Care. Annals of Internal Medicine 148, 111–123.
Ethics of Quality Improvement
OHRP's Conclusion Regarding Consent Erroneous
The authors review the Office for Human Research Protections (OHRP) suspension of a quality improvement research project, aimed at reducing catheter-related infections in the intensive care unit at 67 Michigan hospitals, from both ethical and regulatory perspectives. They conclude that the institutional review board "should have undertaken a full or expedited review of the study protocol instead of deeming it exempt." They also believe that OHRP was incorrect in its conclusion that informed consent was necessary for the improvement project to continue. F. G. Miller and E. J. Emanuel (2008) Quality Improvement Research and Informed Consent. New England Journal of Medicine 358, 765–767.
QI, Not Human Subjects Research
This perspective reviews the Office for Human Research Protections' decision to suspend an intervention that aimed to reduce infections in the intensive care units of 67 Michigan hospitals. The author writes: "In my view, the project was a combination of quality improvement and research on organizations, not human subjects research, and the regulations did not apply." She concludes that the regulations need to be modified or reinterpreted to "protect people from risky research without discouraging low-risk, data-guided activities designed to make our health care system work better." M. A. Baily (2008) Harming Through Protection? New England Journal of Medicine 358, 768–769.
Financial Incentives for Quality
Limiting Payment for Preventable Errors
Medicare plans to withhold additional payments for "serious preventable events," beginning in 2009. The authors review this new policy and conclude that it "seems reasonable if evidence demonstrates that most of the adverse events can be prevented by widespread adoption of achievable practices, the events can be measured accurately, the events resulted in clinically significant patient harm, and [present on admission] determination is feasible." However, close monitoring of this new Medicare policy will be necessary, they say, as it will likely lead to "instances of unfairness, gaming, and unforeseen consequences." R. M. Wachter et al. (2008) Medicare's Decision to Withhold Payment for Hospital Errors: The Devil Is in the Details. Joint Commission Journal on Quality and Patient Safety 34, 116–123.
Reduced Copayments Improve Medication Adherence
A large employer's value-based insurance initiative, designed to improve adherence to recommended treatment regimens, was found to reduce copayments for five chronic medication classes in the context of a disease management program. Medication adherence increased for four of five medication classes, reducing nonadherence by 7 to14 percent, as compared with a control employer using the same disease management program. The authors conclude that copayment reductions for highly valued services have the potential to increase medication adherence above that achieved by existing disease management programs. M. E. Chernew et al. (2008) Impact of Decreasing Copayments on Medication Adherence Within a Disease Management Environment. Health Affairs 27, 10–112.