David Nicewander

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.

Consequences for Healthcare Quality and Research of the Exclusion of Records From the Death Master File

> In November 2011, the Social Security Administration removed ≈5% of death records from its Death Master File and started excluding ≈40% of new death records, having determined that data submitted electronically by states cannot be publicly shared. Before this determination, the Death Master File provided an accessible source of national vital status data with a short time lag and high specificity and sensitivity and was routinely used by healthcare researchers and hospitals to determine study participants’ survival and to monitor postdischarge outcomes. Its effective loss means comparative effectiveness studies will be unnecessarily delayed, more costly, or unfeasible. Likewise, timely identification and correction of poor hospital performance will be more difficult, undermining the safety and quality of care and threatening hospital financing as the Centers for Medicare and Medicaid launch the Readmissions Reduction Program in October 2012 and link reimbursement to 30-day mortality under the Value-Based Purchasing Program in 2013. In summary, the action of the Social Security Administration will substantially hamper healthcare research and quality. We describe the origins of the Death Master File and the basis for excluding electronically submitted state data. We then examine the consequences for healthcare research and operations, consider alternative sources, and evaluate possible mechanisms to restore a timely national data source. On November 1, 2011, the Social Security Administration (SSA) removed ≈5% of the data in its publicly available Death Master File (DMF) and stopped reporting ≈40% of new deaths.1 The SSA explained that it had determined that §205(r) of the Social Security Act (added by the Act of April 20, 1983)2 prohibits the disclosure of state records that the SSA has been including in the public version of the DMF since 2002.1 This is a “demise of a vital resource”3 that will hamper healthcare outcomes research, as well as …

The Effect of Health Care System Administrator Pay-for-Performance on Quality of Care

BACKGROUND The effectiveness of pay-for-performance (P4P) programs for health care administrators has received little attention. In 2001, Baylor Health Care System (BHCS) began linking supervisor compensation to performance on the Joint Commission core measures. METHODS The effect of the P4P program was assessed on the basis of seven core measures for eligible patients discharged from the five BHCS acute care facilities from July 2001 to June 2005 using core measure-specific random effects logistic models. The time trends in performance were compared for BHCS and other hospitals nationwide reporting data on core measures to the Joint Commission. RESULTS Improved performance for 13,673 patients (17,114 admissions; 4,035 admissions before the intervention and 13,079 after) was associated with exposure to administrator P4P for all individual core measures. This effect persisted following adjustment for age and gender (all p values < .0001) but weakened following adjustment for calendar time. Aspirin at discharge and pneumococcal vaccination performance remained significant following adjustment for calendar time. BHCS hospitals exposed to P4P increased performance on all P4P core measures more rapidly than a random sample of hospitals reporting the same measures, with increases in three of the measures significantly faster. DISCUSSION The evidence provided by the study would have been stronger if it had it been possible to randomize exposure to the quality portion of the P4P program. In addition, BHCS engaged in several quality improvement initiatives that could have affected performance on the core measures. Still, linking administrator compensation to performance on specific clinical quality indicators may help improve health care quality. Further research is needed to clarify the impact of administrator P4P.

A hospital-randomized controlled trial of a formal quality improvement educational program in rural and small community Texas hospitals: one year results

OBJECTIVE To investigate the effectiveness of a quality improvement educational program in rural hospitals. DESIGN Hospital-randomized controlled trial. SETTING PARTICIPANTS A total of 47 rural and small community hospitals in Texas that had previously received a web-based benchmarking and case-review tool. INTERVENTION The 47 hospitals were randomized either to receive formal quality improvement educational program or to a control group. The educational program consisted of two 2-day didactic sessions on continuous quality improvement techniques, followed by the design, implementation and reporting of a local quality improvement project, with monthly coaching conference calls and annual follow-up conclaves. MAIN OUTCOME MEASURES Performance on core measures for community-acquired pneumonia and congestive heart failure were compared between study groups to evaluate the impact of the educational program. RESULTS No significant differences were observed between the study groups on any measures. Of the 23 hospitals in the intervention group, only 16 completed the didactic program and 6 the full training program. Similar results were obtained when these groups were compared with the control group. CONCLUSIONS While the observed results suggest no incremental benefit of the quality improvement educational program following implementation of a web-based benchmarking and case-review tool in rural hospitals, given the small number of hospitals that completed the program, it is not conclusive that such programs are ineffective. Further research incorporating supporting infrastructure, such as physician champions, financial incentives and greater involvement of senior leadership, is needed to assess the value of quality improvement educational programs in rural hospitals.

The effects of interdisciplinary outpatient geriatrics on the use, costs and quality of health services in the fee-for-service environment

Background and aims: To evaluate the effect of interdisciplinary outpatient geriatrics on the use, cost, and quality of health services in a fee-for-service (FFS) environment of two networks of primary care clinics operated by a not-for-profit provider organization in Dallas County, Texas. Methods: The Senior Health Network (SHN) provides interdisciplinary primary care to patients aged 55 years or older; the Health Texas Provider Network (HTPN) provides “usual” primary care to patients of all ages. We conducted a two-year retrospective cohort study of 13,098 fee-for-service Medicare beneficiaries who had 2+ visits to one of the networks in 2000. In the SHN, interdisciplinary teams supplemented primary care with social services, specialized clinics, andhealth education. We compared the use, cost and quality of health services, as reflected by paid Medicare claims, provided to eligible patients in the SHN vs the HTPN. Results: Medicare payments for hospital, skilled nursing facility, and home health care services were lower for SHN patients than HTPN patients (−32.7%, −19.8%, and −23.8%, respectively, p≤0.05). SHN patients had a lower likelihood of admission to hospitals for treatment of five “ambulatory care sensitive conditions” (aOR 0.69, 95% CI 0.58–0.81), and they were less likely to receive several preventive services. Total Medicare payments for the two cohorts did not differ significantly. Conclusions: Interdisciplinary outpatient geriatric care in a FFS setting has the potential to avert hospital admissions for ambulatory care sensitive conditions and to reduce Medicare payments for hospital, skilled nursing facility, and home health care services.

A hospital-randomized controlled trial of an educational quality improvement intervention in rural and small community hospitals in Texas following implementation of information technology.

Rural and small community hospitals typically have few resources and little experience with quality improvement (QI) and, on average, demonstrate poorer quality of care than larger facilities. Formalized QI education shows promise in improving quality, but little is known about its effect in rural and small community hospitals. The authors describe a randomized controlled trial assigning 47 rural and small community Texas hospitals to such a program (n = 23) or to the control group (n = 24), following provision of a Web-based quality benchmarking and case review tool. Centers for Medicare and Medicaid Services Core Measures composite scores for congestive heart failure (CHF) and community-acquired pneumonia (CAP), using Texas Medical Foundation data collected via the QualityNet Exchange system, are compared for the groups, for 2 years postintervention. Given the estimated baseline rates for the CHF (68%) and CAP (66%) composites, the cohort enables the detection of 14% and 11% differences (α = .05; power = 0.8), respectively. (Am J Med Qual 2007;22:418-427)

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.

Challenges in Conducting a Hospital-Randomized Trial of an Educational Quality Improvement Intervention in Rural and Small Community Hospitals

The study design for this hospital-randomized controlled trial of an educational quality improvement intervention in rural and small community hospitals, following the implementation of a Web-based quality benchmarking and case review tool, specified a control group and a rapid-cycle quality improvement education group of ≥ 30 hospitals each. Of the 64 hospitals initially interested in participating, 7 could not produce the required quality data and 10 refused consent to randomization. Of the 23 hospitals randomized to the educational intervention, 16 completed the educational program, 1 attended the didactic sessions but did not complete the required quality improvement project, 3 enrolled in “make-up” sessions, and 3 were unable to attend. Of the 42 individuals who attended educational sessions, 5 (12%) have left their positions. Quality improvement interventions require several different approaches to engage participating organizations and should include plans to train new staff given the high turnover of health care quality improvement personnel. (Am J Med Qual 2008;23: 440-447)

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.