Quality Tools in Practice
Improving Diabetic LDL Levels
This study aimed to test the effectiveness of electronic and direct (i.e., face-to-face) educational detailing, or outreach, to enhance lipid testing among diabetic adults. A cohort of 884 diabetic patients at 12 primary care practices were randomized to one of three intervention groups: electronic educational detailing, direct educational detailing, or control. Fifteen months later, researchers assessed whether patients in the three groups had lipid screenings and changes in LDL cholesterol levels. The electronic and direct interventions—both of which are low cost—favorably affected provider behavior regarding dyslipidemia care for diabetic patients. P. S. Mehler et al. (2005) Bridging the Quality Gap in Diabetic Hyperlipidemia: A Practice-Based Intervention. American Journal of Medicine 118, 1414.e13–1414.e19.
Implementing Pneumonia Guidelines
Evidence shows that physicians often overestimate the probability of death in low-risk patients with pneumonia, leading to costly hospitalizations instead of outpatient treatment. A cluster-randomized, controlled trial compared the effectiveness of three strategies for implementing pneumonia guidelines—defined by their varying levels of activity as low-intensity, moderate-intensity, and high-intensity—among emergency departments in Connecticut and Pennsylvania. The authors found that more low-risk patients were treated as outpatients in the moderate-intensity and high-intensity groups than in the low-intensity group. Also, both outpatients and inpatients in the high-intensity group were more likely to receive all four recommended processes of care. D. M. Yealy et al. (2005) Effect of Increasing the Intensity of Implementing Pneumonia Guidelines: A Randomized, Controlled Trial. Annals of Internal Medicine 143, 881–894.
E-Mail Intervention Prevents Hyperlipidemia
This trial evaluated the impact of a computer-assisted intervention to improve secondary prevention of hyperlipidemia in patients with coronary artery disease. The intervention relied on automated population surveillance for high-risk patients with elevated low-density lipoprotein cholesterol levels to trigger an e-mail linked to patients' electronic health records. Physicians then received a single e-mail—independent of a clinical visit—that provided decision-support and facilitated "one-click" order writing. The authors found significant improvement in the secondary prevention of hyperlipidemia at one month after the intervention and identified a trend toward improvement one year later. W. T. Lester et al. (2006) Randomized Controlled Trial of an Informatics-Based Intervention to Increase Statin Prescription for Secondary Prevention of Coronary Disease. Journal of General Internal Medicine 21, 22–29.
Collaborative Approach Reduces Complications
A case series with pre- and post- intervention comparison was conducted for hip-fracture patients nine months before and 33 months after implementing a collaborative approach designed to reduce postoperative complications. This intervention included: assigning patients to an admitting service using a simple clinical algorithm; implementing evidence-based guidelines and order sets for perioperative care; using a nurse specialist to facilitate adherence to evidence-based interventions and mobility goals; and giving patients and families an educational brochure highlighting the daily hospital course. The authors report that the percentage of patients with any postoperative complications fell from nearly 60 percent to less than 10 percent by the end of the study. W. P. Moran et al. (2006) Using a Collaborative Approach to Reduce Postoperative Complications for Hip- Fracture Patients: A Three-Year Follow-Up. Joint Commission Journal on Quality and Patient Safety 32, 16–23.
Error Identification and Prevention
Patient Safety Systems Need Improvement
This study assessed patient safety among all of the acute care hospitals in two states (Missouri and Utah) at two points in time (2002 and 2004). These two states collaborated on an Agency for Healthcare Research and Quality–funded patient safety project following the release of Institute of Medicine (IOM) reports on medical errors and quality. The survey found that the development and implementation of patient safety systems "is at best modest" and, further, "not close to meeting IOM recommendations." The authors conclude that efforts for improvement must be accelerated. D. R. Longo et al. (2005) The Long Road to Patient Safety: A Status Report on Patient Safety Systems. Journal of the American Medical Association 294, 2858–2865.
NICU: Misidentifying Patients
This study quantifies the potential for misidentification among neonatal intensive care unit (NICU) patients due to shared surnames, similar-sounding surnames, or similar medical record numbers. The researchers concluded that risk persists—even after exclusion of multiple births, which account for one-third of patient days in the NICU—and is substantially higher than has been reported among other hospitalized populations. J. E. Gray et al. (2006) Patient Misidentification in the Neonatal Intensive Care Unit: Quantification of Risk. Pediatrics 117, e43–e47.
Medication Discrepancies Between Services
Surgical patients may be at risk for medication errors because anesthesiologists and surgeons write separate preoperative medication histories. A prospective observational study found medication and allergy discrepancies between the surgical and anesthesia preoperative medication histories for patients admitted to two surgical intensive care units in an academic medical center. Patient record review found that 58 of 79, or 73 percent, contained at least one discrepancy; 23 percent had different allergy information; 56 percent had different preoperative medications; and 43 percent had different doses or dosing frequencies. The authors conclude that further work is required to improve agreement of patient medication histories between services. S. A. Burda et al. (2005) What Is The Patient Really Taking? Discrepancies Between Surgery and Anesthesiology Preoperative Medication Histories. Quality and Safety in Health Care 14, 414–416.
Communication Between Interns Critical
In interviews employing critical incident technique, 26 first-year resident physicians caring for 82 hospitalized patients identified 25 adverse events or near misses due to suboptimal patient sign-out—the written or verbal communications that govern transfer of patient care between physicians. These incidents included omitted content (such as medications, active problems, pending tests) and failure-prone communication processes (such as lack of face-to-face discussion). The authors note that such communication failures can lead to uncertainty in patient care decisions. V. Arora et al. (2005) Communication Failures in Patient Sign-Out and Suggestions for Improvement: A Critical Incident Analysis. Quality and Safety in Health Care 14, 401–407.
Cost Containment
Nurse Staffing and Quality
This study simulated different approaches to nurse staffing using data from 799 acute care general hospitals in 11 states. It found that raising the proportion of registered nurses relative to licensed practical/vocational nurses, without increasing the total number of licensed nursing hours per patient, could potentially result in nearly 5,000 fewer patient deaths and generate net savings of $242 million over the short term and $1.8 billion over time. The authors conclude that an "unequivocal business case" can be made for raising the proportion of RNs without changing licensed hours. J. Needleman et al. (2006) Nurse Staffing In Hospitals: Is There A Business Case For Quality? Health Affairs 25, 204–211.
Pay-for-Performance
Medicaid and Care Management
A telephone survey was used to measure the adoption of care management processes (CMPs) by medical groups, independent practice associations, community clinics, and hospital-based clinics in California's Medicaid program, Medi-Cal. The authors found that organizations with more extensive involvement in Medi-Cal managed care used more CMPs for chronic illness and preventive service. Also, the use of CMPs by Medicaid HMOs and the presence of external (both financial and nonfinancial) incentives for clinical performance were strongly associated with use of care management by provider organizations. D. R. Rittenhouse and J. C. Robinson. (2006) Improving Quality in Medicaid: The Use of Care Management Processes for Chronic Illness and Preventive Care. Medical Care 44, 47–54.
Medicare P4P Impact Varies
An examination of the impact that Medicare pay-for-performance (P4P) might have on hospital payment revealed variation among all types of hospitals and across all measures within each of the three conditions studied: heart attack, heart failure, and pneumonia. As modeled, hospitals' financial gains and losses initially are expected to be marginal using the Premier Hospital Quality Incentive Demonstration payment rules and somewhat larger under the Medicare Payment Advisory Commission (MedPAC) recommendations. C. N. Kahn III et al. (2006) Snapshot of Hospital Quality Reporting and Pay-For-Performance under Medicare. Health Affairs 25, 148–162.