Measuring Performance
Study Finds Large P4P Pilot Failed to Improve Quality
An observational analysis of patients with acute myocardial infarction found that those receiving treatment at hospitals participating in a voluntary Centers for Medicare and Medicaid Services pay-for-performance (P4P) pilot did not have significantly improved quality of care or outcomes compared with those treated at hospitals not participating in the program. The authors conclude that additional studies are necessary to determine the optimal role of performance incentives in quality improvement initiatives. S. W. Glickman et al. (2007) Pay for Performance, Quality of Care, and Outcomes in Acute Myocardial Infarction. Journal of the American Medical Association 297, 2373–2380.
Asthma P4P Program Accelerated Improvements
An interrupted time series was used to analyze whether aligning a P4P program—which gave 44 pediatric practices the potential to earn up to a 7 percent fee schedule increase—with the objectives set by an asthma improvement collaborative accelerated quality improvements. Under the program, the practices earned between a 2 and 7 percent increase. Between Oct. 1, 2003, and Nov. 30, 2006, the percentage of the network asthma population receiving "perfect care" increased from 4 percent to 88 percent and the percentage receiving the influenza vaccine increased from 22 percent to 62 percent. K. E. Mandel and U. R. Kotagal (2007) Pay for Performance Alone Cannot Drive Quality. Archives of Pediatrics and Adolescent Medicine 161, 650–655.
Medicaid P4P: Provider Communication Key
The authors examine the implementation of financial incentives for physicians at five health plans participating in a Medicaid P4P demonstration. Experience from this program, which focused on improving the timeliness of well-baby care, identified key ingredients of success, including strong communication with providers and placing enough dollars at stake to compensate providers for the effort required to obtain them. The authors also highlight barriers to improvement that future Medicaid P4P efforts should consider. S. Felt-Lisk et al. (2007) Making Pay-For-Performance Work In Medicaid. Health Affairs Web Exclusive, June, 26, 2007.
Coalition Creates Regional Performance Program
A coalition of hospitals and employers in Maine came together to create a single, statewide performance program with sufficient flexibility to account for different settings and evolving standards. Based on common standards, it allocates incentive payments based on methodology that differentiates between adequate and superior performance. G. A. Nalli et al. (2007) Developing A Performance-Based Incentive Program For Hospitals: A Case Study From Maine.Health Affairs 26: 817–824.
Assessing Quality Among High Medicaid Hospitals
This cross-sectional study evaluated hospital quality among institutions serving a large Medicaid population compared with other hospitals, using data from the Hospital Compare Web site and the 2004 American Hospital Association hospital survey. The authors found that non-teaching hospitals serving large proportions of Medicaid patients had lower adherence to 10 quality indicators for myocardial infarction, congestive heart failure, and community-acquired pneumonia than other non-teaching hospitals. However, among teaching institutions, there were few differences between high-Medicaid and other hospitals. L. E. Goldman et al. (2007) Quality of Care in Hospitals with a High Percent of Medicaid Patients. Medical Care 45, 579–583.
Quality Tools in Practice
Pharmacist Intervention Improves Medication Adherence
A randomized, controlled trial found a pharmacist intervention for low-income patients with heart failure improved medication adherence and outcomes compared with usual care. However, the effect dissipated once the trial stopped, suggesting that, to be successful, continuous intervention is needed. M. D. Murray et al. (2007) Pharmacist Intervention to Improve Medication Adherence in Heart Failure; A Randomized Trial. Annals of Internal Medicine 146, 714–725.
Patient Safety
Medical Trainees' Patient Safety Knowledge Limited
A multi-institutional, cross-sectional assessment of patient safety knowledge among residents and medical students found deficiencies across a broad range of training levels, degrees, and specialties. Medical trainees also were unable to assess their limitations in this area, suggesting effective educational interventions are needed. B. P. Kerfoot et al. (2007) Patient Safety Knowledge and Its Determinants in Medical Trainees. Journal of General Internal Medicine 22, 1150–1154.
Working Conditions Affect Patient Safety
An observation study was used to examine the effects of nurse working conditions—including organizational climate measured by a nurse survey; objective measures of staffing, overtime, and wages (derived from payroll data); and hospital profitability and magnet accreditation—on elderly patient safety outcomes in intensive care units. These variables were found to be associated with all outcomes measured, ranging from central line associated bloodstream infections to ventilator-associated pneumonia, catheter-associated urinary tract infections, 30-day mortality, and decubiti. P. W. Stone et al. (2007) Nurse Working Conditions and Patient Safety Outcomes. Medical Care 45, 571–578.
Information Technology
Health Information Technology Reviewed
The authors provide an overview of the current state of health information technology (HIT). They start with a definition, move on to the benefits and risks of adoption, discuss the current prevalence of HIT and efforts to promote use, and end by looking forward to the future of HIT. D. Blumenthal and J. P. Glaser (2007) Information Technology Comes to Medicine. New England Journal of Medicine 356, 2527–2534.
Improvement Models
Improving Health Care Through Population Segmentation
The authors discuss a model that divides the population into eight groups and sets population-focused priorities for their health. Using this framework, called the "Bridges to Health" model, they interpret these priorities in the context of the Institute of Medicine's six goals for quality to ensure that each person's health needs can be met effectively and efficiently. J. Lynn et al. (2007) Using Population Segmentation to Provide Better Health Care for All: The "Bridges to Health" Model. Millbank Quarterly 85, June, 2007.
Reengineering Hospital Discharge to Improve Outcomes
This article reviews the modifiable components of the hospital discharge process, during which failures can cause medical errors and an array of postdischarge adverse events and rehospitalizations. The authors use a multimethod analysis to describe principles thought to be important to the discharge process and delineate the "reengineered discharge"—a set of 11 discrete and mutually reinforcing components they believe should be part of every hospital discharge. J. L. Greenwald et al. (2007) The Hospital Discharge: A Review of a High Risk Care Transition With Highlights of a Reengineered Discharge Process. Journal of Patient Safety 3, 97–106.
Low Literacy Limits Patient Questions, Participation
This study found low-literacy adults asked significantly fewer questions about medical care issues and fewer questions overall compared with patients with higher literacy. Low-literacy patients also were more likely to ask a physician to repeat something and less likely to use medical terminology, refer to medications by name, request additional services, or seek new information. The authors conclude that patients' literacy may affect their ability to learn about their medical conditions and treatments in health care encounters. M. G. Katz et al. (2007) Patient Literacy and Question-Asking Behavior During the Medical Encounter: A Mixed-methods Analysis. Journal of General Internal Medicine 22, 782–786.
Study Finds Large P4P Pilot Failed to Improve Quality
An observational analysis of patients with acute myocardial infarction found that those receiving treatment at hospitals participating in a voluntary Centers for Medicare and Medicaid Services pay-for-performance (P4P) pilot did not have significantly improved quality of care or outcomes compared with those treated at hospitals not participating in the program. The authors conclude that additional studies are necessary to determine the optimal role of performance incentives in quality improvement initiatives. S. W. Glickman et al. (2007) Pay for Performance, Quality of Care, and Outcomes in Acute Myocardial Infarction. Journal of the American Medical Association 297, 2373–2380.
Asthma P4P Program Accelerated Improvements
An interrupted time series was used to analyze whether aligning a P4P program—which gave 44 pediatric practices the potential to earn up to a 7 percent fee schedule increase—with the objectives set by an asthma improvement collaborative accelerated quality improvements. Under the program, the practices earned between a 2 and 7 percent increase. Between Oct. 1, 2003, and Nov. 30, 2006, the percentage of the network asthma population receiving "perfect care" increased from 4 percent to 88 percent and the percentage receiving the influenza vaccine increased from 22 percent to 62 percent. K. E. Mandel and U. R. Kotagal (2007) Pay for Performance Alone Cannot Drive Quality. Archives of Pediatrics and Adolescent Medicine 161, 650–655.
Medicaid P4P: Provider Communication Key
The authors examine the implementation of financial incentives for physicians at five health plans participating in a Medicaid P4P demonstration. Experience from this program, which focused on improving the timeliness of well-baby care, identified key ingredients of success, including strong communication with providers and placing enough dollars at stake to compensate providers for the effort required to obtain them. The authors also highlight barriers to improvement that future Medicaid P4P efforts should consider. S. Felt-Lisk et al. (2007) Making Pay-For-Performance Work In Medicaid. Health Affairs Web Exclusive, June, 26, 2007.
Coalition Creates Regional Performance Program
A coalition of hospitals and employers in Maine came together to create a single, statewide performance program with sufficient flexibility to account for different settings and evolving standards. Based on common standards, it allocates incentive payments based on methodology that differentiates between adequate and superior performance. G. A. Nalli et al. (2007) Developing A Performance-Based Incentive Program For Hospitals: A Case Study From Maine.Health Affairs 26: 817–824.
Assessing Quality Among High Medicaid Hospitals
This cross-sectional study evaluated hospital quality among institutions serving a large Medicaid population compared with other hospitals, using data from the Hospital Compare Web site and the 2004 American Hospital Association hospital survey. The authors found that non-teaching hospitals serving large proportions of Medicaid patients had lower adherence to 10 quality indicators for myocardial infarction, congestive heart failure, and community-acquired pneumonia than other non-teaching hospitals. However, among teaching institutions, there were few differences between high-Medicaid and other hospitals. L. E. Goldman et al. (2007) Quality of Care in Hospitals with a High Percent of Medicaid Patients. Medical Care 45, 579–583.
Quality Tools in Practice
Pharmacist Intervention Improves Medication Adherence
A randomized, controlled trial found a pharmacist intervention for low-income patients with heart failure improved medication adherence and outcomes compared with usual care. However, the effect dissipated once the trial stopped, suggesting that, to be successful, continuous intervention is needed. M. D. Murray et al. (2007) Pharmacist Intervention to Improve Medication Adherence in Heart Failure; A Randomized Trial. Annals of Internal Medicine 146, 714–725.
Patient Safety
Medical Trainees' Patient Safety Knowledge Limited
A multi-institutional, cross-sectional assessment of patient safety knowledge among residents and medical students found deficiencies across a broad range of training levels, degrees, and specialties. Medical trainees also were unable to assess their limitations in this area, suggesting effective educational interventions are needed. B. P. Kerfoot et al. (2007) Patient Safety Knowledge and Its Determinants in Medical Trainees. Journal of General Internal Medicine 22, 1150–1154.
Working Conditions Affect Patient Safety
An observation study was used to examine the effects of nurse working conditions—including organizational climate measured by a nurse survey; objective measures of staffing, overtime, and wages (derived from payroll data); and hospital profitability and magnet accreditation—on elderly patient safety outcomes in intensive care units. These variables were found to be associated with all outcomes measured, ranging from central line associated bloodstream infections to ventilator-associated pneumonia, catheter-associated urinary tract infections, 30-day mortality, and decubiti. P. W. Stone et al. (2007) Nurse Working Conditions and Patient Safety Outcomes. Medical Care 45, 571–578.
Information Technology
Health Information Technology Reviewed
The authors provide an overview of the current state of health information technology (HIT). They start with a definition, move on to the benefits and risks of adoption, discuss the current prevalence of HIT and efforts to promote use, and end by looking forward to the future of HIT. D. Blumenthal and J. P. Glaser (2007) Information Technology Comes to Medicine. New England Journal of Medicine 356, 2527–2534.
Improvement Models
Improving Health Care Through Population Segmentation
The authors discuss a model that divides the population into eight groups and sets population-focused priorities for their health. Using this framework, called the "Bridges to Health" model, they interpret these priorities in the context of the Institute of Medicine's six goals for quality to ensure that each person's health needs can be met effectively and efficiently. J. Lynn et al. (2007) Using Population Segmentation to Provide Better Health Care for All: The "Bridges to Health" Model. Millbank Quarterly 85, June, 2007.
Reengineering Hospital Discharge to Improve Outcomes
This article reviews the modifiable components of the hospital discharge process, during which failures can cause medical errors and an array of postdischarge adverse events and rehospitalizations. The authors use a multimethod analysis to describe principles thought to be important to the discharge process and delineate the "reengineered discharge"—a set of 11 discrete and mutually reinforcing components they believe should be part of every hospital discharge. J. L. Greenwald et al. (2007) The Hospital Discharge: A Review of a High Risk Care Transition With Highlights of a Reengineered Discharge Process. Journal of Patient Safety 3, 97–106.
Low Literacy Limits Patient Questions, Participation
This study found low-literacy adults asked significantly fewer questions about medical care issues and fewer questions overall compared with patients with higher literacy. Low-literacy patients also were more likely to ask a physician to repeat something and less likely to use medical terminology, refer to medications by name, request additional services, or seek new information. The authors conclude that patients' literacy may affect their ability to learn about their medical conditions and treatments in health care encounters. M. G. Katz et al. (2007) Patient Literacy and Question-Asking Behavior During the Medical Encounter: A Mixed-methods Analysis. Journal of General Internal Medicine 22, 782–786.