Charles P. Schade

Self-Reported Household Impacts of Large-Scale Chemical Contamination of the Public Water Supply, Charleston, West Virginia, USA

A January 2014 industrial accident contaminated the public water supply of approximately 300,000 homes in and near Charleston, West Virginia (USA) with low levels of a strongly-smelling substance consisting principally of 4-methylcyclohexane methanol (MCHM). The ensuing state of emergency closed schools and businesses. Hundreds of people sought medical care for symptoms they related to the incident. We surveyed 498 households by telephone to assess the episode’s health and economic impact as well as public perception of risk communication by responsible officials. Thirty two percent of households (159/498) reported someone with illness believed to be related to the chemical spill, chiefly dermatological or gastrointestinal symptoms. Respondents experienced more frequent symptoms of psychological distress during and within 30 days of the emergency than 90 days later. Sixty-seven respondent households (13%) had someone miss work because of the crisis, missing a median of 3 days of work. Of 443 households reporting extra expenses due to the crisis, 46% spent less than

Quality of ambulatory care for diabetes and lower-extremity amputation.

100, while 10% spent over

Improving Self-Reporting of Adverse Drug Events in a West Virginia Hospital

500 (estimated average about

Impact of the 2004 Influenza Vaccine Shortage on Repeat Immunization Rates

206). More than 80% (401/485) households learned of the spill the same day it occurred. More than 2/3 of households complied fully with “do not use” orders that were issued; only 8% reported drinking water against advice. Household assessments of official communications varied by source, with local officials receiving an average “B” rating, whereas some federal and water company communication received a “D” grade. More than 90% of households obtained safe water from distribution centers or stores during the emergency. We conclude that the spill had major economic impact with substantial numbers of individuals reporting incident-related illnesses and psychological distress. Authorities were successful supplying emergency drinking water, but less so with risk communication.

Using Statewide Audit and Feedback to Improve Hospital Care in West Virginia

Lower extremity amputation (LEA) is a serious complication of diabetes. We sought to determine whether quality of ambulatory care affects risk of LEA. We conducted a claims-based case-control study of 409 Medicare beneficiaries younger than age 75 with diabetes and LEA between January 1, 2003, and December 31, 2005. They were matched with controls with diabetes without LEA, on age, gender, number of diabetes outpatient visits, and (for those with hospital admissions between January 1, 2000, and December 31, 2002) number of comorbid conditions, diabetes complications, and peripheral vascular disease. Quality-of-care measures for cases and controls covered the period April 1, 1999, through March 31, 2001. LEA patients were less likely to have had lipid screening than controls (odds ratio = 0.73; 95% confidence interval = 0.53-0.99), and controls were more likely to use physicians with high performance in lipid screening (χ 2 = 6.631, P = .012) and hemoglobin A1c testing (χ 2 = 6.079, P = .014). (Am J Med Qual 2007;22:410-417)

Improving the Home Health Acute-Care Hospitalization Quality Measure

Adverse drug events significantly increase length of stay and costs of hospitalization but are underre-ported in health care institutions. We hypothesized that hospitals could improve the accuracy of adverse drug event self-reporting by comparing adverse drug events recorded in an occurrence reporting tool with those detected by surveillance of “rescue” drugs administered to treat adverse drug events. We conducted a prospective cohort study of all adult inpatient discharges from a 200-bed rural acute care hospital in West Virginia during a 6-month period. We performed 3572 chart audits, of which 1011 included rescue drug administration. Our outcome measure was the proportion of adverse drug events in the rescue drug surveillance that were found in the occurrence reporting tool. We found that less than 4% of all adverse drug events involving use of rescue drugs were reported. We concluded that underreporting of preventable adverse drug events in this hospital is comparable to published rates and that surveillance of adverse drug events to detect underreporting is feasible.

Promoting Influenza and Pneumococcal Immunization in Older Adults

PURPOSE We assessed the impact of the severe influenza vaccine shortage of 2004 on individual physicians’ immunization performance. METHODS Using 1998–2004 Medicare claims data, we monitored the physician continuity rate (proportion of patients receiving influenza immunization from a physician in 1 year who received a subsequent immunization from the same physician the subsequent year) and other clinician rate (proportion of patients with claims from 1 physician in 1 year with a claim from another clinician the subsequent year) in West Virginia Medicare beneficiaries from 2000–2004. We examined vaccine claim trends by clinician and surveys of self-reported immunization to determine whether patients received vaccine from nonphysician clinicians or went without immunization each year. RESULTS Claims-based influenza vaccination rates increased from 35.5% to 41.3% from 2000–2003, reflecting historical trends, before declining 14.1% in 2004. Median continuity rates among the 723 to 849 physicians claiming 25 or more influenza immunizations from 2000–2003 increased from 47% in 2000–2001 to 54% in 2002–2003; then fell to 3% in 2003–2004. The number of physicians filing 100 or more claims declined from 337 in 2003 to 130 in 2004. More than 25% of physicians had no repeat vaccinations of the same beneficiaries in 2004. Trends in clinician type and survey data indicated a shift of many beneficiaries to mass vaccinators and institutional providers; however, compared with previous years, there was an estimated 8% increase in 2004 in the number of West Virginia beneficiaries who did not receive vaccine. CONCLUSIONS The 2004 vaccine shortage had a severe impact on influenza immunization rates in private physician’s offices, disrupting continuity of care.

Exploratory analysis of the relationship between home health agency engagement in a national campaign and reduction in acute care hospitalization in US home care patients

BACKGROUND Audit and feedback systems have significantly improved medical care in numerous settings, and they appear to work by stimulating competition rather than through command and control. METHODS The West Virginia Medical Institute (WVMI), a Medicare-designated Quality Improvement Organization (QIO), periodically collected quality information on five common conditions (acute myocardial infarction [AMI], heart failure, pneumonia, stroke, and atrial fibrillation) that cause hospitalization in Medicare beneficiaries. All 44 acute care hospitals in West Virginia were offered written and orally presented reports of quality performance from 1998 through 2001. RESULTS All indicators appeared to improve statewide. Several--for example, aspirin at discharge for AMI patients and pneumococcal vaccine for pneumonia patients--improved by more than 10 absolute percentage points. Fourteen of 15 quality indicators showed significant improvement (p < .05, paired t-test) in all hospitals between the before- and after-feedback periods. Seven of 13 indicators assessed during the entire study in the largest hospitals showed no significant trends in quality before feedback but significant increases (p < .05, chi-square for trend) in the after-feedback period. DISCUSSION The quality indicator changes reported can represent important health gains for West Virginia Medicare beneficiaries. Most of the improvement did not occur until after hospitals received feedback.

The 2010-2011 home health quality improvement national campaign.

OBJECTIVES (1) To demonstrate average length of service (ALOS) bias in the currently used acute-care hospitalization (ACH) home health quality measure, limiting comparability across agencies, and (2) to propose alternative ACH measures. DATA SOURCES/STUDY SETTING Secondary analysis of Medicare home health service data 2004-2007; convenience sample of Medicare fee-for-service hospital discharges. STUDY DESIGN Cross-sectional analysis and patient-level simulation. DATA COLLECTION/EXTRACTION METHODS We aggregated outcome and ALOS data from 2,347 larger Medicare-certified home health agencies (HHAs) in the United States between 2004 and 2007, and calculated risk-adjusted monthly ACH rates. We used multiple regression to identify agency characteristics associated with ACH. We simulated ACH during and immediately after home health care using patient and agency characteristics similar to those in the actual data, comparing the existing measure with alternative fixed-interval measures. PRINCIPAL FINDINGS Of agency characteristics studied, ALOS had by far the highest partial correlation with the current ACH measure (r(2)=0.218, p<.0001). We replicated the correlation between ACH and ALOS in the patient-level simulation. We found no correlation between ALOS and the alternative measures. CONCLUSIONS Alternative measures do not exhibit ALOS bias and would be appropriate for comparing HHA ACH rates with one another or over time.

Letter to the Editor: Author's Response:

BACKGROUND Reducing the risk of influenza and pneumococcal disease in older adults is a long-standing goal of Medicares Quality Improvement Organization (QIO) program and parallels the Joint Commissions National Patient Safety Goal 10. ADDRESSING THE GOAL Since 1999 the West Virginia Medical Institute has worked with a statewide partnership of health organizations on a program to improve influenza and pneumonia vaccination rates in hospitalized Medicare beneficiaries. Methods included education, audit and feedback, toolkits, and training meetings. RESULTS During the first three years (1999-2001) of the effort, the rate of assessment for pneumococcal immunization at discharge increased from < 10% to 74.1% statewide and for influenza immunization from near zero to 63.4% statewide. Since 2002 pneumococcal immunization administration has increased from 16.1% to 41.1%, with similar improvement in influenza measures. LESSONS LEARNED/NEXT STEPS Hospitals--and, by extension, long term care facilities--can make dramatic improvements in quality performance in a relatively short time when key staff receive feedback about the need to improve and the tools to assist in improving.