Quality Tools in Practice
Collaboratives Improve Care Processes
A controlled pre- and post-intervention study of community health centers participating in the Health Resources and Services Administration–sponsored Health Disparities Collaboratives found these centers had considerably greater improvement in the quality of care for diabetes and asthma—but not hypertension—than centers that had not participated. Also, though the collaboratives significantly improved the processes of care for two of the three conditions, there was no improvement in clinical outcomes. B. E. Landon et al. (2007) Improving the Management of Chronic Disease at Community Health Centers. New England Journal of Medicine 356, 921–934. Also see related editorial, R. A. Hayward (2007) Performance Measurement in Search of a Path. New England Journal of Medicine 356, 951–953.
Interventions Improve Discharge Communication
A review of observation studies investigating communication and information transfer at hospital discharge found: infrequent direct communication between hospital providers and primary care physicians; low availability of discharge summaries, affecting quality of care in a quarter of follow-up visits; and discharge summaries lacking important information. Controlled studies evaluating the efficacy of interventions to improve information transfer identified several practices, such as use of computer-generated summaries and standardized formats, that led to more timely discharge communications. S. Kripalani et al. (2007) Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians: Implications for Patient Safety and Continuity of Care. Journal of the American Medical Association 297, 831–841.
Care Coordination Affects Outcomes, Satisfaction
Unilateral knee-replacement patients (n=222) at Brigham and Women's Hospital in Boston were surveyed about the coordination of their post-discharge care during a six-week period, during which they received care from rehabilitation facilities and/or home care agencies as well as follow-up care from their surgeons. The authors found problems with coordination across settings and between providers and patients. At six weeks after surgery, these problems were associated with greater joint pain, lower functioning, and lower patient satisfaction; at 12 weeks, they were associated with greater joint pain but not with functional status. D. B. Weinberg et al. (2007) Beyond Our Walls: Impact of Patient and Provider Coordination Across the Continuum on Outcomes for Surgical Patients. Health Services Research 42, 7–24.
Error Identification and Prevention
Pediatricians Support Error Disclosure, Need Better Systems
A cross-sectional survey was used to measure the attitudes and experiences of 439 pediatric attending physicians and 118 residents regarding error communication. While most respondents endorsed reporting errors to the hospital (97% endorsed reporting of serious errors, 90% for reporting of minor errors, and 82% for near misses), only 39 percent thought that current error reporting systems were adequate. They reported using both formal and informal error reporting mechanisms. Also, most endorse disclosing serious or minor errors to patients' families and many had done so. J. Garbutt et al. (2007) Reporting and Disclosing Medical Errors: Pediatricians' Attitudes and Behaviors. Archives of Pediatrics and Adolescent Medicine 161, 179–185.
Cost Containment
Developing a Business Case for Quality Improvement
The authors describe the 11 steps necessary to develop a business case for quality-enhancing interventions (QEIs) in health care: 1) describing the intervention, 2) determining perspective, 3) identifying the effects of the intervention on quality, 4) designing the study, 5) identifying and measuring cash flows, 6) considering the effects of capacity constraints, 7) selecting a measure of return on investment, 8) determining the time horizon for the analysis, 9) determining the discount rate, 10) adjusting costs and savings for inflation, and 11) determining organizational readiness for business case development. The authors conclude that delineating the cost and economic implications of investments in QEIs is a critical threshold issue to widespread adoption of evidence-based quality improvements. K. L. Reiter et al. (2007) How to Develop a Business Case for Quality. International Journal for Quality in Health Care 19, 50–55.
Information Technology
Review of EHR Data May Underestimate Performance
An observational study was used to evaluate whether automated review of electronic health record (EHR) data accurately measures quality of care for outpatients with heart failure. The authors compared automated review with hybrid review, or automated review followed by a manual review of electronic notes for patients with apparent quality deficits. Though performance levels were similar for three measures (assessing left ventricular ejection fraction, prescription of beta blockers, and prescription of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers), performance based on automated review was lower than that based on hybrid review for the prescription of warfarin for atrial fibrillation. The authors conclude that automated reviews can miss medication exclusion criteria documented in providers' notes, thus underestimating performance on related quality measures. D.W. Baker et al. (2007) Automated Review of Electronic Health Records to Assess Quality of Care for Outpatients with Heart Failure. Annals of Internal Medicine 146, 270–277.
"Most Wired" Outperform Other Hospitals
This study compared hospitals labeled "Most Wired"—a hospital or member hospital of a health system listed among the Hospital and Health Network's Healthcare's Most Wired Hospitals for 2004—to those without that designation across 10 cardiac and pulmonary measures. The authors found "Most Wired" hospitals outperformed other hospitals in all but one quality indicator. However, some of the results were significantly attenuated by other factors associated with quality, suggesting that, for specific indicators, "Most Wired" may be a marker of overall quality more than an independent factor. F. Yu and T. K. Houston (2007) Do "Most Wired" Hospitals Deliver Better Care? Joint Commission Journal on Quality and Patient Safety 33, 136–144.
Measuring Performance
Pay for Performance Linked to Improvement
Adherence to 10 individual and four composite quality measures was assessed over a two-year period at 613 hospitals that voluntarily reported information about the quality of care through a national public-reporting initiative. This assessment included 207 facilities participating in a Centers for Medicare and Medicaid Services–funded pay-for-performance demonstration. Multivariable modeling found pay-for-performance hospitals showed greater improvement (ranging from 2.6 to 4.1%) in all composite measures of quality than hospitals not participating in the demonstration. The authors conclude that more research is needed to determine whether different incentives would stimulate more improvement and whether the benefits of these programs outweigh their costs. P. K. Lindenauer et al. (2007) Public Reporting and Pay for Performance in Hospital Quality Improvement. New England Journal of Medicine 356, 486–496.
Better Heart Failure Performance Measures Needed
Sixty- to 90-day post-discharge data were prospectively collected from 5,791 patients at 91 U.S. hospitals, enabling the authors to examine the relationship between current American College of Cardiology/American Heart Association performance measures for hospitalized heart failure patients and relevant clinical outcomes. They found that current heart failure performance measures, with the exception of prescription of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker at discharge, have little relationship to patient mortality and combined mortality/rehospitalization after discharge. G. C. Fonarow et al. (2007) Association Between Performance Measures and Clinical Outcomes for Patients Hospitalized with Heart Failure. Journal of the American Medical Association 297, 61–70.
Enabling Population-Based Assessments of Provider Cost and Quality
One challenge in measuring the quality of care is to make reliable connections between patients and their particular health care providers and hospitals. This study developed a method for creating "ambulatory provider specific cohorts": Medicare beneficiaries were assigned to their predominant ambulatory physician and then to the hospital where that physician provided inpatient services, or where a plurality of that physician's patient panel had medical admissions. This method enables population-based assessments of provider-specific costs and quality of care and can be used to analyze Medicare claims data. Studying patterns of practice, costs, and outcomes of care could complement other methods used to monitor provider performance, the authors conclude. J. P. W. Bynum et al. (2007) Assigning Ambulatory Patients and Their Physicians to Hospitals: A Method for Obtaining Population-Based Provider Performance Measurements. Health Services Research 42, 45–62.
Collaboratives Improve Care Processes
A controlled pre- and post-intervention study of community health centers participating in the Health Resources and Services Administration–sponsored Health Disparities Collaboratives found these centers had considerably greater improvement in the quality of care for diabetes and asthma—but not hypertension—than centers that had not participated. Also, though the collaboratives significantly improved the processes of care for two of the three conditions, there was no improvement in clinical outcomes. B. E. Landon et al. (2007) Improving the Management of Chronic Disease at Community Health Centers. New England Journal of Medicine 356, 921–934. Also see related editorial, R. A. Hayward (2007) Performance Measurement in Search of a Path. New England Journal of Medicine 356, 951–953.
Interventions Improve Discharge Communication
A review of observation studies investigating communication and information transfer at hospital discharge found: infrequent direct communication between hospital providers and primary care physicians; low availability of discharge summaries, affecting quality of care in a quarter of follow-up visits; and discharge summaries lacking important information. Controlled studies evaluating the efficacy of interventions to improve information transfer identified several practices, such as use of computer-generated summaries and standardized formats, that led to more timely discharge communications. S. Kripalani et al. (2007) Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians: Implications for Patient Safety and Continuity of Care. Journal of the American Medical Association 297, 831–841.
Care Coordination Affects Outcomes, Satisfaction
Unilateral knee-replacement patients (n=222) at Brigham and Women's Hospital in Boston were surveyed about the coordination of their post-discharge care during a six-week period, during which they received care from rehabilitation facilities and/or home care agencies as well as follow-up care from their surgeons. The authors found problems with coordination across settings and between providers and patients. At six weeks after surgery, these problems were associated with greater joint pain, lower functioning, and lower patient satisfaction; at 12 weeks, they were associated with greater joint pain but not with functional status. D. B. Weinberg et al. (2007) Beyond Our Walls: Impact of Patient and Provider Coordination Across the Continuum on Outcomes for Surgical Patients. Health Services Research 42, 7–24.
Error Identification and Prevention
Pediatricians Support Error Disclosure, Need Better Systems
A cross-sectional survey was used to measure the attitudes and experiences of 439 pediatric attending physicians and 118 residents regarding error communication. While most respondents endorsed reporting errors to the hospital (97% endorsed reporting of serious errors, 90% for reporting of minor errors, and 82% for near misses), only 39 percent thought that current error reporting systems were adequate. They reported using both formal and informal error reporting mechanisms. Also, most endorse disclosing serious or minor errors to patients' families and many had done so. J. Garbutt et al. (2007) Reporting and Disclosing Medical Errors: Pediatricians' Attitudes and Behaviors. Archives of Pediatrics and Adolescent Medicine 161, 179–185.
Cost Containment
Developing a Business Case for Quality Improvement
The authors describe the 11 steps necessary to develop a business case for quality-enhancing interventions (QEIs) in health care: 1) describing the intervention, 2) determining perspective, 3) identifying the effects of the intervention on quality, 4) designing the study, 5) identifying and measuring cash flows, 6) considering the effects of capacity constraints, 7) selecting a measure of return on investment, 8) determining the time horizon for the analysis, 9) determining the discount rate, 10) adjusting costs and savings for inflation, and 11) determining organizational readiness for business case development. The authors conclude that delineating the cost and economic implications of investments in QEIs is a critical threshold issue to widespread adoption of evidence-based quality improvements. K. L. Reiter et al. (2007) How to Develop a Business Case for Quality. International Journal for Quality in Health Care 19, 50–55.
Information Technology
Review of EHR Data May Underestimate Performance
An observational study was used to evaluate whether automated review of electronic health record (EHR) data accurately measures quality of care for outpatients with heart failure. The authors compared automated review with hybrid review, or automated review followed by a manual review of electronic notes for patients with apparent quality deficits. Though performance levels were similar for three measures (assessing left ventricular ejection fraction, prescription of beta blockers, and prescription of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers), performance based on automated review was lower than that based on hybrid review for the prescription of warfarin for atrial fibrillation. The authors conclude that automated reviews can miss medication exclusion criteria documented in providers' notes, thus underestimating performance on related quality measures. D.W. Baker et al. (2007) Automated Review of Electronic Health Records to Assess Quality of Care for Outpatients with Heart Failure. Annals of Internal Medicine 146, 270–277.
"Most Wired" Outperform Other Hospitals
This study compared hospitals labeled "Most Wired"—a hospital or member hospital of a health system listed among the Hospital and Health Network's Healthcare's Most Wired Hospitals for 2004—to those without that designation across 10 cardiac and pulmonary measures. The authors found "Most Wired" hospitals outperformed other hospitals in all but one quality indicator. However, some of the results were significantly attenuated by other factors associated with quality, suggesting that, for specific indicators, "Most Wired" may be a marker of overall quality more than an independent factor. F. Yu and T. K. Houston (2007) Do "Most Wired" Hospitals Deliver Better Care? Joint Commission Journal on Quality and Patient Safety 33, 136–144.
Measuring Performance
Pay for Performance Linked to Improvement
Adherence to 10 individual and four composite quality measures was assessed over a two-year period at 613 hospitals that voluntarily reported information about the quality of care through a national public-reporting initiative. This assessment included 207 facilities participating in a Centers for Medicare and Medicaid Services–funded pay-for-performance demonstration. Multivariable modeling found pay-for-performance hospitals showed greater improvement (ranging from 2.6 to 4.1%) in all composite measures of quality than hospitals not participating in the demonstration. The authors conclude that more research is needed to determine whether different incentives would stimulate more improvement and whether the benefits of these programs outweigh their costs. P. K. Lindenauer et al. (2007) Public Reporting and Pay for Performance in Hospital Quality Improvement. New England Journal of Medicine 356, 486–496.
Better Heart Failure Performance Measures Needed
Sixty- to 90-day post-discharge data were prospectively collected from 5,791 patients at 91 U.S. hospitals, enabling the authors to examine the relationship between current American College of Cardiology/American Heart Association performance measures for hospitalized heart failure patients and relevant clinical outcomes. They found that current heart failure performance measures, with the exception of prescription of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker at discharge, have little relationship to patient mortality and combined mortality/rehospitalization after discharge. G. C. Fonarow et al. (2007) Association Between Performance Measures and Clinical Outcomes for Patients Hospitalized with Heart Failure. Journal of the American Medical Association 297, 61–70.
Enabling Population-Based Assessments of Provider Cost and Quality
One challenge in measuring the quality of care is to make reliable connections between patients and their particular health care providers and hospitals. This study developed a method for creating "ambulatory provider specific cohorts": Medicare beneficiaries were assigned to their predominant ambulatory physician and then to the hospital where that physician provided inpatient services, or where a plurality of that physician's patient panel had medical admissions. This method enables population-based assessments of provider-specific costs and quality of care and can be used to analyze Medicare claims data. Studying patterns of practice, costs, and outcomes of care could complement other methods used to monitor provider performance, the authors conclude. J. P. W. Bynum et al. (2007) Assigning Ambulatory Patients and Their Physicians to Hospitals: A Method for Obtaining Population-Based Provider Performance Measurements. Health Services Research 42, 45–62.