David J. Ballard

Influence of coronary heart disease on morbidity and mortality after lower extremity revascularization surgery: A population-based study in Olmsted County, Minnesota (1970–1987)☆

OBJECTIVES The aim of this study was to evaluate the short- and long-term postoperative cardiac outcome of patients undergoing lower extremity revascularization surgery in a geographically defined patient group. BACKGROUND Among patients with peripheral vascular disease, cardiac events have an important effect on long-term outcome after peripheral vascular surgery. However, long-term outcome is poorly documented. METHODS We examined the entire community medical records of 173 residents of Olmsted County, Minnesota, who underwent peripheral artery bypass surgery between 1970 and 1987 and were followed up to January 1, 1991. Patients were allocated to subgroups of 60 patients with and 106 patients without overt coronary artery disease. RESULTS There were no significant differences in perioperative death, myocardial infarction or stroke between subgroups at 30 days after operation. The 5- and 10-year Kaplan-Meier survival rate after operation was 77% and 51% in those without and 54% and 24% in those with overt coronary artery disease (p < 0.001), respectively. For both groups, survival was significantly poorer than that expected for an age- and gender-matched group. Patients undergoing aortoiliac surgery were more likely to be alive at 10 years than those undergoing femoropopliteal surgery (47% vs. 28%, p = 0.001). The 5-year cumulative incidence of cardiac events was greater in those with overt coronary artery disease (50% vs. 28%, p = 0.003). In multivariable analysis, age, coronary artery disease and diabetes were independent predictors of death. CONCLUSIONS Coronary events are the most important cause of long-term morbidity and mortality after peripheral vascular surgery. Patients without overt coronary artery disease are at significant risk for long-term cardiac events.

Improving quality and reducing inequities: a challenge in achieving best care

The health care quality chasm is better described as a gulf for certain segments of the population, such as racial and ethnic minority groups, given the gap between actual care received and ideal or best care quality. The landmark Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century challenges all health care organizations to pursue six major aims of health care improvement: safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness. “Equity” aims to ensure that quality care is available to all and that the quality of care provided does not differ by race, ethnicity, or other personal characteristics unrelated to a patients reason for seeking care. Baylor Health Care System is in the unique position of being able to examine the current state of equity in a typical health care delivery system and to lead the way in health equity research. Its organizational vision, “culture of quality,” and involved leadership bode well for achieving equitable best care. However, inequities in access, use, and outcomes of health care must be scrutinized; the moral, ethical, and economic issues they raise and the critical injustice they create must be remedied if this goal is to be achieved. Eliminating any observed inequities in health care must be synergistically integrated with quality improvement. Quality performance indicators currently collected and evaluated indicate that Baylor Health Care System often performs better than the national average. However, there are significant variations in care by age, gender, race/ethnicity, and socioeconomic status that indicate the many remaining challenges in achieving “best care” for all.

The quality of care for Medicare patients with peptic ulcer disease.

OBJECTIVE:The aim of this study was to examine quality of care for hospitalized Medicare beneficiaries with peptic ulcer disease.METHODS:Collaborating with five Peer Review Organizations, we used 1995 Medicare claim files to select samples of inpatients with a principal diagnosis of peptic ulcer disease. Quality of care indicators developed by content experts included percentages for ulcer patients tested for Helicobacter pylori (H. pylori); biopsied patients who received tissue tests; H. pylori-positive patients who received appropriate therapy; and ulcer patients screened for preadmission nonsteroidal anti-inflammatory drug (NSAID) use and counseled about risks.RESULTS:Of 2,644 patients eligible for medical record review, 56% were tested for H. pylori, and 73% of those testing positive were treated appropriately; 84% of patients with endoscopic biopsies received a tissue test for H. pylori; 74% of patients were screened for preadmission NSAID use, 24% had documented counseling of NSAID use, and only 2% had documented counseling on the ulcer risk of NSAID use. Statistically significant regional variation occurred in four of six quality indicators. Outpatient records were reviewed for 529 patients to document prior outpatient H. pylori in this population; only 2% (n = 12) were tested for H. pylori in the year before admission.CONCLUSIONS:Opportunities exist to improve quality of care by testing for and treating H. pylori in hospitalized Medicare beneficiaries with peptic ulcer disease and to improve screening for NSAIDs and counseling on ulcer risks.

Quality of Care of Medicare Patients With Diabetes in a Metropolitan Fee-for-Service Primary Care Integrated Delivery System

Diabetes care in the United States is suboptimal. Although closed-panel health maintenance organizations (HMOs) and the Department of Veterans Affairs (VA) report performance superior to national norms, fee-for-service performance is uncertain. To address this issue, 3 outcome and 5 process indicators were measured for 2010 Medicare diabetes patients across 22 sites in a large, fee-for-service primary care group practice. American Diabetes Association standards for glycemic control, low-density lipoprotein cholesterol, and blood pressure were met by 53%, 46%, and 19% of patients, respectively. Diabetes Quality Improvement Project/Alliance poor control markers for the same measures were exceeded by 9%, 20%, and 54% of patients. Chart abstraction demonstrated annual eye examination, foot examination, and nephropathy screening rates of 16%, 49%, and 38%, while Medicare claims showed an annual eye examination rate of 63%. Observed processes and outcomes in this fee-for-service setting were superior to reported national performance and similar to the best performance in staff-model HMOs and the VA.

Effectiveness of diabetes resource nurse case management and physician profiling in a fee-for-service setting: a cluster randomized trial.

Nurses with advanced training—diabetes resource nurses (DRNs)—can improve care for people with diabetes in capitated payment settings. Their effectiveness in fee-for-service settings has not been investigated. We conducted a 12-month practice-randomized trial involving 22 practices in a fee-for-service metropolitan network with 92 primary care physicians caring for 1891 Medicare patients ≥65 years with diabetes mellitus. Each practice was randomized to one of three intervention groups: physician feedback on process measures using Medicare claims data; Medicare claims feedback plus feedback on clinical measures from medical record (MR) abstraction; or both types of feedback plus a practice-based DRN. The primary endpoint investigated was hemoglobin A1c level. Other measures were low-density lipoprotein (LDL) cholesterol level, blood pressure, annual hemoglobin A1c testing, annual LDL screening, annual eye exam, annual foot exam, and annual renal assessment. Data were collected from medical chart abstraction and Medicare claims. The number of patients with hemoglobin A1c <9% increased by 4 (0.9%) in the Claims group; 9 (2.1%) in the Claims + MR group (comparison with Claims: P = 0.97); and 16 (3.8%) in the DRN group (comparison with Claims: P = 0.31). Results were similar for the other clinical outcomes, with no differences significant at P = 0.10. For process of care measures, decreases were seen in all groups, with no significant differences in change scores. Quality improvement strategies must be evaluated in the appropriate setting. Initiatives that have been effective in capitated systems may not be effective in fee-for-service environments.

Cost and Effects of Performance Feedback and Nurse Case Management for Medicare Beneficiaries with Diabetes: A Randomized Controlled Trial

Nurse case management has been shown to improve the quality of diabetes care in closed model health maintenance organizations and Veterans Affairs medical clinics. A randomized controlled trial of a similar intervention within HealthTexas Provider Network, a fee-for-service primary care network in North Texas, demonstrated no benefit in processes of care or clinical outcomes for Medicare diabetes patients. To investigate whether the case management model impacted the cost of diabetes care from the Medicare perspective, we compared the average payments and charges incurred between intervention arms: claims-based audit and feedback; claims- and medical-record-based audit and feedback; and claims- and medical-record-based audit and feedback plus a practice-based diabetes resource nurse. Following adjustment for baseline differences between groups, no significant differences were observed. Thus, within this setting, it appears the nurse case management model produced no improvement in either clinical quality or in costs associated with diabetes from a Medicare perspective.

Patient-centeredness and timeliness in a primary care network: baseline analysis and power assessment for detection of the effects of an electronic health record.

Electronic health records are expected to improve all six dimensions of quality care identified by the Institute of Medicine (safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness). HealthTexas Provider Network, the ambulatory care network affiliated with the Baylor Health Care System in Dallas–Fort Worth, Texas, is implementing a networkwide ambulatory electronic health record (AEHR). To evaluate the quality of care and financial impact of the AEHR implementation, we examined the available indicators for quantitatively measuring performance in each dimension of quality. For patient-centeredness, the primary data source available is the patient satisfaction survey. To achieve a broad view of patient-centeredness, we identified two measures of satisfaction (overall satisfaction with the physician and willingness to refer the physician) to be examined individually and used additional survey items to construct physician interaction and organizational scales. These scales showed good reliability (Cronbach alpha = 0.95 and 0.89, respectively) and predictive ability ranging from 77% to 93% when applied to the overall satisfaction measures. Data from September 2003 to June 2006 showed mean pre-AEHR implementation baseline performance of 22.9 (±3.3) on the 25-point physician interaction scale and 38.0 (±5.8) on the 45-point organizational scale; 70.9% of patients reported excellent satisfaction with their physician, and 97.6% of patients reported willingness to refer. Timeliness data were collected using the same survey. Baseline performance showed that 43.4% of patients waited ≤2 days between making and keeping an appointment, and 50.6% of patients waited ≤5 minutes past appointment time. However, 12.5% waited >30 days between making and keeping an appointment, and 14.0% waited >30 minutes past appointment time. The power to detect changes in the patient-centeredness and timeliness measures in the 3-year multiple time series evaluation of the quality and financial impact of the AEHR was investigated and showed that even small changes in these measures will be detectable.

Financial performance of primary care physician practices prior to electronic health record implementation

While electronic health records (EHRs) are being widely implemented across the nation, few empirical data are currently available regarding their potential impact on financial performance and resource use. HealthTexas Provider Network is implementing a networkwide EHR, providing a unique opportunity to describe and evaluate fiscal effects. We conducted a retrospective, longitudinal observational study of financial performance related to inputs and income- and productivity-related outputs for the 33 primary care practices (July 2002–April 2006). Models for each outcome were constructed to test for a linear trend over time, adjusted for practice characteristics. F tests based on these models were used to determine the effect of each adjustor and to determine existence of a trend in each outcome. The observed staff per physician full-time equivalent (FTE) (3.6) was similar to staffing ratios reported for other primary care–only practices, while observation of 4692 work relative value units per physician FTE annually was higher than reported nationally. Significant monthly trends were identified for three of the outcome measures. During the pre-EHR baseline period, staffing ratios were equivalent to and physician productivity greater than reports available for these measures nationally or in other settings. Identification of time trends in three measures will allow these to be accounted for in the model used to evaluate the financial performance impact of EHR implementation.

Accelerating Best Care at Baylor Dallas

A culture of quality improvement (QI) is needed to bridge the gap between possible STEEEP™ (safe, timely, effective, efficient, equitable, and patient-centered) care and actual usual care. Baylor Health Care System (BHCS) developed Accelerating Best Care at Baylor (ABC Baylor), an innovative educational program that teaches health care leaders the theory and techniques of rapid-cycle QI. Course participants learn general principles of continuous QI, as well as health care–specific QI techniques, and finish the course by designing and implementing their own QI project. ABC Baylor has been employed in a variety of settings and has spread its success to other organizations, especially small and rural hospitals. These hospitals, like BHCS, have demonstrated sustained improvements that are due in part to the use of ABC Baylor and its reliance on specific modules that focus on health care safety, service, equity, and chronic disease management. The role of ABC Baylor training and consulting is part of the overall culture and infrastructure that have allowed BHCS to achieve success in its improvement journey, including the receipt of several national awards and the achievement of high reliability in compliance with Centers for Medicare and Medicaid Services core measures of processes of care related to heart failure, acute myocardial infarction, community-acquired pneumonia, and surgical care. The culture of rapid-cycle QI facilitated by ABC Baylor serves to link BHCSs vision and goals to practical execution.

Impact of clinical preventive services in the ambulatory setting

Indicators of the performance of clinical preventive services (CPS) have been adopted in the ambulatory setting to improve quality of care. The impact of CPS was evaluated in a network of 49 primary care practices providing care to an estimated 245,000 adults in the Dallas–Fort Worth area through a sample chart review to determine delivery of recommended evidence-based CPS combined with medical literature estimates of the effectiveness of CPS. In this population in 2005, CPS were estimated to have prevented 36 deaths and 97 incident cases of cancer; 420 coronary heart disease events (including 66 sudden deaths) and 118 strokes; 816 cases of influenza and pneumonia (including 24 hospital admissions); and 87 osteoporosis-related fractures. Thus, CPS have substantial benefits in preventing deaths and illness episodes.