Elizabeth Mort

Primary care physician attitudes concerning follow-up of abnormal test results and ambulatory decision support systems

OBJECTIVES Failures to follow-up abnormal test results are common in ambulatory care. Information systems could assist providers with abnormal test result tracking, yet little is known about primary care providers attitudes toward outpatient decision support systems. METHODS A cross-sectional survey of 216 primary care physicians (PCPs) that utilize a single electronic medical record (EMR) without computer-based clinical decision support. RESULTS The overall response rate was 65% (140/216). Less than one-third of the respondents were satisfied with their current system to manage abnormal laboratory, radiographs, Pap smear, or mammograms results. Only 15% of providers were satisfied with their system to notify patients of abnormal results. Over 90% of respondents felt automated systems to track abnormal test results would be useful. Seventy-nine percent of our respondents believed that they could comply better with guidelines through electronic clinical reminders. CONCLUSIONS Most PCPs were not satisfied with their methods for tracking abnormal results. Respondents believed that clinical decision support systems (CDSS) would be useful and could improve their ability to track abnormal results.

Contemporary performance of U.S. teaching and nonteaching hospitals.

Purpose To compare the performance of U.S. teaching and nonteaching hospitals using a portfolio of contemporary, publicly reported metrics. Method The authors classified acute care general hospitals filing a Medicare Institutional Cost Report according to teaching intensity: nonteaching, teaching, or Council of Teaching Hospitals member. They compared aggregate results across categories for Hospital Compare process compliance, mortality, and readmission rates (acute myocardial infarction [AMI], heart failure, pneumonia); Surgical Care Improvement Project (SCIP) performance; compliance with Leapfrog standards; patient experience; patient services and key technologies; safety (computerized physician order entry, intensive care unit staffing, National Quality Forum safe practices, hospital-acquired conditions); and cost/resource utilization (Medicare-adjusted expense per case; Leapfrog efficiency and resource use standards). Results Availability of patient services and advanced technologies were associated with teaching intensity (P < .0001), as were most hospital safety metrics. Teaching intensity was favorably associated with SCIP performance, AMI and heart failure process scores, and mortality (P < .0001). It was unfavorably associated with higher AMI and pneumonia readmission rates (P < .0001) and lower scores for individual patient satisfaction measures. Costs per case were similar (P = .4194) across hospital categories after correction for federally allowed adjustments (case mix, wages, and low-income patient care). Conclusions Teaching hospitals offer advanced clinical capabilities, educate the next generation of providers, care for disadvantaged urban populations, and are leaders in health care research and innovation. However, many stakeholders may be unaware of an additional value—relatively higher quality and safety in many areas, with similar adjusted costs.

Association of National Hospital Quality Measure adherence with long-term mortality and readmissions

Background In existing studies, the association between adherence with recommended hospital care processes and subsequent outcomes has been inconsistent. This has substantial implications because process measure scores are used for accountability, quality improvement and reimbursement. Our investigation addresses methodological concerns with previous studies to better clarify the process–outcomes association for three common conditions. Methods The study included all patients discharged from Massachusetts General Hospital between 1 July 2004 and 31 December 2007 with a principle diagnosis of acute myocardial infarction (AMI), heart failure (HF) or pneumonia (PN) who were eligible for at least one National Hospital Quality Measure. The number of patients analysed varied by measure (374 to 3020) depending on Centers for Medicare and Medicaid Services eligibility criteria. Hospital data were linked with state administrative data to determine mortality and readmissions. For patients with multiple admissions, the time-weighted impact of measure failures on mortality was estimated using exponential decay functions. All patients had follow-up for at least 1 year or until death or readmission. Cox models were used to estimate HRs adjusted for transfer status, age, gender, race, census block-group socioeconomic status, number of Elixhauser comorbidities, and do not resuscitate orders. Results Adjusted survival and freedom from readmission for AMI and PN showed superior results for 100% and 50–99% adherence compared with 0–49% adherence. For HF, the results were inconsistent and sometimes paradoxical, although several individual measures (eg, ACE inhibitor/angiotensin receptor blockade) were associated with improved outcomes. Conclusion Adherence with recommended AMI and PN care processes is associated with improved long-term outcomes, whereas the results for HF measures are inconsistent. The evidence base for all process measures must be critically evaluated, including the strength of association between these care processes and outcomes in real-world populations. Some currently recommended processes may not be suitable as accountability measures.

Lessons from Implementing a Combined Workflow–Informatics System for Diabetes Management

Shortcomings surrounding the care of patients with diabetes have been attributed largely to a fragmented, disorganized, and duplicative health care system that focuses more on acute conditions and complications than on managing chronic disease. To address these shortcomings, we developed a diabetes registry population management application to change the way our staff manages patients with diabetes. Use of this new application has helped us coordinate the responsibilities for intervening and monitoring patients in the registry among different users. Our experiences using this combined workflow-informatics intervention system suggest that integrating a chronic disease registry into clinical workflow for the treatment of chronic conditions creates a useful and efficient tool for managing disease.

Reporting Trends and Outcomes in ST-Segment–Elevation Myocardial Infarction National Hospital Quality Assessment Programs

Background— For patients who undergo primary percutaneous coronary intervention (PCI) for ST-segment–elevation myocardial infarction, the door-to-balloon time is an important performance measure reported to the Centers for Medicare & Medicaid Services (CMS) and tied to hospital quality assessment and reimbursement. We sought to assess the use and impact of exclusion criteria associated with the CMS measure of door-to-balloon time in primary PCI. Methods and Results— All primary PCI-eligible patients at 3 Massachusetts hospitals (Brigham and Women’s, Massachusetts General, and North Shore Medical Center) were evaluated for CMS reporting status. Rates of CMS reporting exclusion were the primary end points of interest. Key secondary end points were between-group differences in patient characteristics, door-to-balloon times, and 1-year mortality rates. From 2005 to 2011, 26% (408) of the 1548 primary PCI cases were excluded from CMS reporting. This percentage increased over the study period from 13.9% in 2005 to 36.7% in the first 3 quarters of 2011 (P<0.001). The most frequent cause of exclusion was for a diagnostic dilemma such as a nondiagnostic initial ECG, accounting for 31.2% of excluded patients. Although 95% of CMS-reported cases met door-to-balloon time goals in 2011, this was true of only 61% of CMS-excluded cases and consequently 82.6% of all primary PCI cases performed that year. The 1-year mortality for CMS-excluded patients was double that of CMS-included patients (13.5% versus 6.6%; P<0.001). Conclusions— More than a quarter of patients who underwent primary PCI were excluded from hospital quality reports collected by CMS, and this percentage has grown substantially over time. These findings may have significant implications for our understanding of process improvement in primary PCI and mechanisms for reimbursement through Medicare.

Improving Access to Palliative Care through an Innovative Quality Improvement Initiative: An Opportunity for Pay-for-Performance

BACKGROUND Improving access to palliative care is an important priority for hospitals as they strive to provide the best care and quality of life for their patients. Even in hospitals with longstanding palliative care programs, only a small proportion of patients with life-threatening illnesses receive palliative care services. Our two well-established palliative care programs in large academic hospitals used an innovative quality improvement initiative to broaden access to palliative care services, particularly to noncancer patients. METHODS The initiative utilized a combination of electronic and manual screening of medical records as well as intensive outreach efforts to identify two cohorts of patients with life-threatening illnesses who, according to University HealthSystems Consortium (UHC) benchmarking criteria, would likely benefit from palliative care consultation. Given the differing cultures and structure of the two institutions, each service developed a unique protocol for identifying and consulting on suitable patients. RESULTS Consultation rates in the target populations tripled following the initiative: from 16% to 46% at one hospital and from 15% to 48% at the other. Although two different screening and identification processes were developed, both successfully increased palliative care consultations in the target cohorts. CONCLUSION Quality improvement strategies that incorporate pay-for-performance incentives can be used effectively to expand palliative care services to underserved populations.

A Comparison of the Preventive Health Care Provided by Women's Health Centers and General Internal Medicine Practices

AbstractOBJECTIVE: To evaluate women’s health centers as alternatives to traditional internal medicine practices. DESIGN: Cross-sectional mailed survey. SETTING: A women’s health center and an internal medicine practice at each of three university-affiliated teaching hospitals. PATIENTS: There were 3,035 female patients randomly selected to receive a mailed survey after their office visits. MEASUREMENTS AND MAIN RESULTS: The survey asked for patient characteristics, patient satisfaction, and rates of gender-specific preventive health services. The survey response rate was 64% (1,942/3,035). Patients at women’s health centers were younger, more educated, had higher physical functioning but lower mental health functioning, and more of them were single and employed. Patient satisfaction was similar at the two types of practices, although patients at women’s health centers were more satisfied with certain aspects of the patient-provider interaction. After adjusting for measured differences in patient characteristics and site, patients at women’s health centers were more likely to receive discussions on hormone replacement therapy (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.1, 2.2) and dietary calcium (OR 1.3; 95% CI 1.1, 1.6). They were also more likely to receive their gender-specific preventive health services from their primary care provider: breast examination (OR 2.0; 95% CI 1.5, 2.6), Pap smear (OR 2.4; 95% CI 1.9, 3.1), hormone replacement therapy discussion (OR 2.2; 95% CI 1.5, 3.3), and dietary calcium discussion (OR 2.6; 95% CI 1.7, 3.9). These findings remained when the analyses were limited to patients of female providers only. CONCLUSIONS: In this study, patients at women’s health centers were more likely to receive gender-specific health prevention counseling than patients at internal medicine practices. Moreover, patients were more likely to receive their gender-specific preventive health services from their primary care providers.

Restructuring Within an Academic Health Center to Support Quality and Safety: The Development of the Center for Quality and Safety at the Massachusetts General Hospital

Recent focus on the need to improve the quality and safety of health care has created new challenges for academic health centers (AHCs). Whereas previously quality was largely assumed, today it is increasingly quantifiable and requires organized systems for improvement. Traditional structures and cultures within AHCs, although well suited to the tripartite missions of teaching, research, and clinical care, are not easily adaptable to the tasks of measuring, reporting, and improving quality. Here, the authors use a case study of Massachusetts General Hospitals efforts to restructure quality and safety to illustrate the value of beginning with a focus on organizational culture, using a systematic process of engaging clinical leadership, developing an organizational framework dependent on proven business principles, leveraging focus events, and maintaining executive dedication to execution of the initiative. The case provides a generalizable example for AHCs of how applying explicit management design can foster robust organizational change with relatively modest incremental financial resources.

Documentation of Decision-Making Capacity, Informed Consent, and Health Care Proxies: A Study of Surrogate Consent

BACKGROUND Patients in the general hospital are routinely asked to make decisions about their medical care. However, some of them are unable to express a choice, understand the information provided, weigh the options, or make a decision for themselves; when this occurs, the task of making an appropriate medical decision is left to another-a substitute decision-maker (SDM). OBJECTIVE We sought to understand the practice patterns surrounding surrogate consent. We hypothesized that SDMs would be used frequently for patients with an altered mental status (AMS) but that there would be insufficient documentation of health care proxies (HCP) and of clinician assessment of a patients decision-making capacity. METHODS A retrospective chart review was conducted on inpatients who underwent a lumbar puncture. The review assessed whether patients had a HCP in the record, if the patients mental status was evaluated prior to obtaining informed consent, if the patients capacity was addressed in this assessment, and whether a SDM was asked to provide the informed consent. RESULTS Consistent with our hypotheses, we found that the majority of patients did not have documentation of a HCP in the record. We found that the mental status of all patients was assessed prior to the procedure, but that documentation regarding assessment of decision-making capacity was lacking. CONCLUSIONS Our pilot investigation suggests that there is need for improvement in our evaluation and documentation of altered mental status and a patients ability to make informed decisions. To this end, several quality-improvement suggestions are discussed.

Queuing Theory to Guide the Implementation of a Heart Failure Inpatient Registry Program

OBJECTIVE The authors previously implemented an electronic heart failure registry at a large academic hospital to identify heart failure patients and to connect these patients with appropriate discharge services. Despite significant improvements in patient identification and connection rates, time to connection remained high, with an average delay of 3.2 days from the time patients were admitted to the time connections were made. Our objective for this current study was to determine the most effective solution to minimize time to connection. DESIGN We used a queuing theory model to simulate 3 different potential solutions to decrease the delay from patient identification to connection with discharge services. MEASUREMENTS The measures included average rate at which patients were being connected to the post discharge heart failure services program, average number of patients in line, and average patient waiting time. RESULTS Using queuing theory model simulations, we were able to estimate for our current system the minimum rate at which patients need to be connected (262 patients/mo), the ideal patient arrival rate (174 patients/mo) and the maximal patient arrival rate that could be achieved by adding 1 extra nurse (348 patients/mo). CONCLUSIONS Our modeling approach was instrumental in helping us characterize key process parameters and estimate the impact of adding staff on the time between identifying patients with heart failure and connecting them with appropriate discharge services.